This week in Medicare updates—8/12/2020
New ABN Form Mandatory Use Extension
On August 3, CMS published a Notice on its website to state that the deadline for mandatory use of the new ABN form has now been changed to January 1, 2021. The previous date for mandated use of the new form was August 31, 2020. The instructions for the new form have a new section for dually eligible beneficiaries.
New OIG Toolkits on Emergency Response
On August 3, the OIG published two Emergency Response Toolkits designed to help health care providers and community responders with the COVID-19 pandemic and other emergencies. The toolkits were created based on insights from OIG reports on previous emergencies, such as infectious disease outbreaks, natural disasters, and bioterrorism.
2021 Medicare Physician Fee Schedule (MPFS) Proposed Rule
On August 3, CMS published a draft copy of the 2021 MPFS Proposed Rule, which is scheduled to be published in the Federal Register on August 17. The rule contains a proposal to decrease the conversion factor down from $36.09 in 2020 to $32.26 in 2021 (11% decrease) while revising RVUs for certain E/M code categories, a move which could result in significant payment changes for certain specialties. CMS is moving forward with its changes to documentation guidelines for office/outpatient E/M codes, effective January 1, 2021, to align with changes made by the AMA. Other proposals in the rule include:
- Extending certain flexibilities introduced during the PHE, such as scope of practice extensions and modified supervision requirements, either permanently or through the end of CY 2021
- Adding nine services to the telehealth list on a permanent basis and 13 services to the telehealth on a temporary category 3 basis
- Clarifying policies regarding remote physiologic monitoring services
- Implementing provisions of the SUPPORT Act regarding substance and opioid use disorders
- Codifying changes to the Clinical Laboratory Fee Schedule data reporting period and the phase-in of payment reductions
CMS is seeking comments on a variety of topics from the rule, especially as they pertain to telehealth services or flexibilities initially introduced due to the COVID-19 PHE. Comments on the rule are due no later than 5 p.m. ET on October 5.
As with the 2021 IPPS rule-making process, CMS is waiving the 60-day delay in the effective date of the final rule and replacing it with a 30-day delay in the effective date, meaning the final rule will likely be published later this year than the usual early November publication date.
CMS published a Fact Sheet and Press Release on the rule on the same date as well as a Fact Sheet on Medicare Diabetes Prevention Program policies which are being revised during the remainder of the PHE and any future applicable 1135 waiver event.
2021 Quality Payment Program Proposed Rule
On August 3, CMS published a draft copy of the 2021 MPFS Proposed Rule, which is scheduled to be published in the Federal Register on August 17. The rule contains provisions for the 2021 changes to the Quality Payment Program (QPP). Some of the proposals include:
- Delaying establishment of the MIPS Value Pathways to 2022
- Using data submitted during the CY 2021 performance period to establish performance benchmarks for the CY 2021 MIPS performance period
- CMS would typically use baseline period historical data, but it is concerned the data from 2020 will be skewed due to the COVID-19 pandemic
- Changing MIPS performance category weights for the Quality and Cost categories
- Quality will be worth 40% in 2021 instead of 45%
- Cost will be worth 20% in 2021 instead of 15%
CMS published a Fact Sheet specifically on the QPP changes on the same date. Comments on the MPFS proposed rule are due no later than 5 p.m. on October 5.
2021 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Prospective Payment System (ASC PPS) Proposed Rule
On August 4, CMS published a draft copy of the 2021 OPPS and ASC PPS Proposed Rule, which is scheduled to be published in the Federal Register on August 12. CMS is proposing to update both OPPS and ASC PPS payment rates by 2.6% for 2021. Other proposals in the rule include:
- Eliminating the inpatient-only (IPO) list over a three-year period, beginning with the removal of almost 300 musculoskeletal-related services in 2021. Procedures removed from the IPO list would eventually become subject to the 20midnight rule.
- Reimbursing hospitals for 340B drugs at a net rate of average sales price (ASP) minus 28.7%. That rate was based on the results of a hospital survey conducted earlier in 2020 and is calculated with a base reimbursement of ASP minus 34.7% combined with a 6% add-on payment for overhead and handling.
- Expanding prior authorization to include two additional service categories effective for dates of service on or after July 1, 2021: (1) cervical fusion with disc removal and (2) implanted spinal neurostimulators.
- Changing supervision levels for non-surgical extended duration therapeutic services (NSEDTS) to general supervision for the entire service as a minimum requirement.
- Adding 11 procedures to the ASC covered procedures list and proposing two alternatives that would change the way procedures are added to that list.
CMS is seeking comments on a variety of topics within the rule, including how best to execute the elimination of the IOP list, whether the 340B reimbursement should remain at ASP minus 22.5%, and more. Comments are due no later than 5 p.m. ET on October 5.
As with the 2021 IPPS rule-making process, CMS is waiving the 60-day delay in the effective date of the final rule and replacing it with a 30-day delay in the effective date, meaning the final rule will likely be published later this year than the usual early November publication date.
CMS published a Fact Sheet and Press Release on the rule on the same date.
FY 2021 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) Final Rule
On August 4, CMS published a draft copy of the FY 2021 IRF PPS Final Rule, which is scheduled to be published in the Federal Register on August 10. CMS is updating IRF PPS total payments by 2.8% for FY 2021 and will adopt the most recent OMB statistical area delineations while also applying a 5% cap on wage index decreases from 2020 to 2021. CMS is also finalizing the permanent elimination of post-admission physician evaluations, amending coverage requirements to allow non-physician practitioners to perform one of three required visits in weeks two and beyond of a patient’s care, and codifying certain documentation and guidance for coverage requirements.
CMS published a Fact Sheet and Press Release on the rule on the same date. Regulations from the rule are effective October 1, 2020.
Request for Information: Electronic Prescribing of Controlled Substances
On August 4, CMS published a Request for Information in the Federal Register regarding a requirement in the SUPPORT Act that, effective January 1, 2021, prescriptions for controlled substances must be transmitted electronically by a healthcare provider in accordance with an electronic prescription drug program. The request for information is seeking comment on whether CMS should include exceptions to the electronic prescribing of controlled substances (EPCS) mandate, which circumstances should qualify for exceptions, and whether CMS should impose penalties/what the penalties should be for noncompliance with this mandate.
Comments are due no later than 5 p.m. on October 5.
FAQs: Application of OIG’s Administrative Enforcement Authorities to Arrangements Directly Connected to the COVID-19 Public Health Emergency
On August 4, the OIG updated an FAQ regarding changes to enforcement pertaining to arrangements that are directly connected to COVID-19. The new FAQ pertains to clinical laboratories offering free COVID-19 antibody testing.
FAQs: COVID-19 Testing at Skilled Nursing Facilities/Nursing Homes
On August 5, CMS published an FAQ on the distribution of COVID-19 antigen tests to nursing homes. It covers which devices will be sent, when nursing facilities can expect to receive them, training on how to use the tests, safety precautions, and more.
Updated Provider Self-Disclosure Settlements
On August 5, the OIG published an updated List of Provider Self-Disclosure Settlements with three new settlements with facilities that employed individuals they knew or should have known were excluded from federal healthcare programs. This includes:
- 6932 W. Sunrise Boulevard Operations, LLC d/b/a NSpire Healthcare Plantation, of Florida
- Medical Faculty Associates d/b/a GW Medical Faculty Associates, of Washington, D.C.
- MHC Healthcare d/b/a Marana Health Center, of Arizona
Updated List of Excluded Individuals and Entities (LEIE)
On August 6, the OIG updated its LEIE with an updated LEIE database for download and lists of July 2020 exclusions, reinstatements, and profile corrections.
Updated Corporate Integrity Agreement Documents
On August 6, the OIG published information on a new Corporate Integrity Agreement with Brooklyn Plaza Medical Center, of Brooklyn, NY. It also published information on closed cases with:
- Baptist Health, Baptist Health Medical Center-Little Rock, and Baptist Health Medical Center-North Little Rock, of Little Rock, AR
- Ana M. Gama, D.D.S. Inc., Ana M. Gama, D.D.S., of Rialto, CA
- Norman, M.D., James and Norman Parathyroid Center, P.A., of Wesley Chapel, FL
- Singulex, Inc., of Alameda, CA
Proposed Rule: Treatment of Medicare Part C Days in the Calculation of a Hospital’s Medicare Disproportionate Patient Percentage
On August 6, CMS published a Proposed Rule in the Federal Register regarding a policy in which the calculation of a hospital’s disproportionate patient percentage would include patients enrolled in Medicare Part C for cost reporting periods starting before FY 2014. The rule was issued in response to the ruling from Azar v. Allina Health Services from June 3, 2019.
Comments on the proposed rule are due no later than 5 p.m. on October 5, 2020.
Some Nursing Homes’ Reported Staffing Levels in 2018 Raise Concerns; Consumer Transparency Could Be Increased
On August 6, the OIG published a Report on nursing home staffing in 2018. The OIG found that 7% of nursing homes reported staffing levels below requirements for at least 30 days in 2018, and another 7% reporting inadequate staffing levels between 16 and 29 days in 2018. Most of the days reported fell on weekends, leading to concerns that nursing homes did not have staff to fully meet resident needs in 2018. The OIG also found that CMS incentives for staffing levels did not address the daily variations in staffing, and the way information is presented to consumers about nursing home staffing also fails to show daily differences in staffing levels.
The OIG recommends CMS enhance efforts to ensure nursing homes meet daily staffing requirements and explore ways to provide consumers with additional information on nursing homes’ daily staffing levels and variability.
Expand Retention of Claims History for Outpatient, Part B, and DMEPOS to 5 Years
On August 6, CMS published One-Time Notification Transmittal 10291, which rescinds and replaces Transmittal 10104 (the red text in the revised transmittal incorrectly states the original transmittal number is 10404), dated May 8, 2020, to revise the effective and implementation dates to move these instructions off the January 2021 release. The original transmittal was issued regarding the expanded retention of outpatient, Part B, and DMEPOS claims history within the CWF for up to five years or 60 months.
Effective date: July 1, 2021
Implementation date: October 5, 2020 - Development; April 5, 2021 - Testing; July 5, 2021 - Integration Testing and Implementation
Inadequate Edits and Oversight Caused Medicare to Overpay More Than $267 Million for Hospital Inpatient Claims with Post-Acute Transfers to Home Health Services
On August 7, the OIG published a Review of whether Medicare properly paid acute care hospital inpatient claims subject to the transfer policy for three different scenarios, including claims not coded as discharge to home with home health services when those home health services resumed within three days of discharge, claims with condition code 43, or claims with condition code 42. The OIG found that CMS improperly paid 147 out of the 150 claims included in the sample and should have paid the graduated per diem rate for those claims rather than full payment. This resulted in a total of $722,288 in improper payments for the sample.
The OIG recommends CMS recover the overpayments identified in the sample and reprocess or reanalyze remaining inpatient claims in the sample frame with incorrect discharge status codes or condition codes 43 or 42. It also recommends CMS correct related system edits, improve provider education on the transfer policy, and identify hospitals disproportionately using condition code 42. The OIG suggests CMS consider taking whatever action necessary to automatically deem any home health service within three days of discharge to be related. CMS concurred with all but this last recommendation.
Update to Osteoporosis Drug Codes Billable on Home Health Claims
On August 7, CMS published Medicare Claims Processing Transmittal 10274 regarding instructions for billing and payment of additional codes for osteoporosis drugs under the home health benefit. These additional codes include J0897 (injection, denosumab, 1 mg), J3111 (injection, romosozumab-aqqg, 1 mg), and J3590 (unclassified code used to report abaloparatide).
Effective date: January 1, 2021 - Claims received on and after this date.
Implementation date: January 4, 2021
Billing for Home Infusion Therapy Services On or After January 1, 2021
On August 7, CMS published Medicare Benefit Policy Transmittal 10269 and Medicare Claims Processing Transmittal 10269 regarding billing guidance and changes to claims processing systems in preparation for the implementation of the new home infusion therapy benefit.
Effective date: January 1, 2021
Implementation date: January 4, 2021
Primary Care First (PCF) and Serious Illness Patient (SIP) Models: Part 2: FFS Payments and Other Claims-Based Adjustments
On August 7, CMS published Demonstrations Transmittal 10281 regarding implementation of certain components of the PCF and SIP Models for the January 2021 release. This transmittal addresses the flat-visit fee HCPCS codes, HCPCS code G2020 (for the SIP component only), and prohibited HCPCS codes from Appendix B.
Effective date: January 1, 2021 - Applicable to the PCF component (excludes beneficiaries and providers from the SIP component); April 1, 2021 - Applicable to the SIP component
Implementation date: January 4, 2021
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
On August 7, CMS published Medicare Claims Processing Transmittal 10265 regarding the October update to the CLFS. The update includes a delay for the next CLFS data reporting period, COVID-19 lab updates, and several code updates.
Effective date: October 1, 2020
Implementation date: October 5, 2020
Telehealth Expansion Benefit Under the Pennsylvania Rural Health Model (PARHM) - Implementation
On August 7, CMS published Demonstrations Transmittal 10282 regarding the expansion of the allowable telehealth services for PARHM participant hospitals. CMS will allow use of asynchronous telehealth and is waiving other requirements to telehealth services for PARHM participants.
Effective date: January 1, 2021
Implementation date: January 4, 2021
Correction to Editing Update for Vaccine Services
On August 7, CMS published One-Time Notification Transmittal 10275 regarding a change to the CWF to bypass line item dates of service for vaccines reported on inpatient Part B claims with TOB 12X and 22X when the dates of service equal a posted outpatient 73X or 77X service dates, or if present, occurrence span code visit date, regardless of the DOS.
Effective date: January 1, 2021 - For claims received on or after this date
Implementation date: January 4, 2021
Utility to Reprocess Bypassed Common Working File (CWF) Informational Unsolicited Responses (IUR)
On August 7, CMS published One-Time Notification Transmittal 10271 regarding a reusable process that will allow CMS to direct reprocessing of bypassed IURs. This will initially be used for recouping OIG-identified overpayments for post-acute transfer IPPS claims.
Effective date: January 1, 2021; April 1, 2021
Implementation date: January 4, 2021 - Analysis and Design; April 5, 2021 - Coding, Testing, and Implementation
User CR: ViPS Medicare System (VMS) - Enhancements to the Claim Edit Audit Trail Screen (BUDS05)
On August 7, CMS published One-Time Notification Transmittal 10287 regarding an update to the VMS Beneficiary Update and Display System (BUDS) to allow users to display claims by entering a single Claim Control Number.
Effective date: January 1, 2021
Implementation date: January 4, 2021
Instructions for Retrieving the January 2021 Opioid Treatment Program (OTP) Payment Rates Through the CMS Mainframe Telecommunications System
On August 7, CMS published Medicare Claims Processing Transmittal 10285 regarding instructions to the MACs to download, test, and implement the OTP update file. It also instructs the contractors to be prepared to implement up to three payment files for the January update in the event that technical errors are discovered.
Effective date: January 1, 2021
Implementation date: January 4, 2021
Create a New Media Preference Indicator Custom Format and New eMedicare Correspondence Preference Indicator
On August 7, CMS published One-Time Notification Transmittal 10278 regarding an update to the Medicare systems to allow and process Medicare beneficiary preferences for communications and notifications in various accessible formats.
Effective date: January 1, 2021 - CWF shall develop and make available all copybooks as described in the BRs. FISS, MCS, VMS and CWF shall perform Analysis/Design; April 1, 2021 - FISS, MCS, VMS and CWF shall develop and implement; July 1, 2021 - BR 11746.1.11.1 only to implement and validate ECPS changes.
Implementation date: January 4, 2021 - CWF shall develop and make available all copybooks as described in the BRs. FISS, MCS, VMS and CWF shall perform Analysis/Design; April 5, 2021 - FISS, MCS, VMS and CWF shall develop and implement; July 6, 2021 - BR 11746.1.11.1 only to implement and validate ECPS changes.