This week in Medicare updates—8/26/2020
New Waivers for Inpatient Prospective Payment System (IPPS) Hospitals, Long-Term Care Hospitals (LTCH), and Inpatient Rehabilitation Facilities (IRF) due to Provisions of CARES Act
On August 17, CMS revised Special Edition MLN Matters 20015 to update information regarding the implementation of Section 3710 of the CARES Act as it applies to eligibility for a 20% increase in the MS-DRG weighting factor. The original transmittal was issued regarding provisions of the CARES ACT which apply to IPPS hospitals, LTCHs, and IRFs.
CMS Updates Toolkit on State Actions to Mitigate COVID-19 Prevalence in Nursing Homes
On August 17, CMS updated a Toolkit regarding actions and best practices that organizations and state governments are taking to help nursing homes meet the needs of residents during the pandemic. CMS intends for providers and nursing home administrators to use this document to learn about different plans state governments and other public health entities have put in place during a short period of time to contain the spread of COVID-19 and protect nursing home residents.
Enforcement Cases Held During the Prioritization Period and Revised Survey Prioritization
On August 17, CMS published a Memorandum to state survey agency directors regarding the resumption of certain survey activity, including onsite revisits, complaint investigations triaged as non-immediate jeopardy medium, and annual recertification surveys required to be conducted within 15 months of a provider’s last recertification survey. The memo also discusses updated guidance for re-prioritization of routine CLIA survey activities, expanded desk review authority, and more.
CMS published a Press Release on the same date to accompany the memo.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state/regional office training coordinators.
Key Components for Continued COVID-19 Management for Dialysis Facilities
On August 17, CMS published a Memorandum to Regional Offices, State Survey Agency Directors, and Dialysis Facility stakeholders regarding guidance and clarification on managing dialysis facility patients, home dialysis services, and essential procedures for dialysis patients during the public health emergency. The memo updates policies to clarify that essential surgical procedures are critical for ESRD patients while recognizing there are some instances where local conditions will not allow for these procedures to happen. CMS is also reinforcing infection control guidance based on CDC recommendations for dialysis facilities.
CMS also published a Press Release and a Checklist for dialysis facilities in COVID-19 hotspots to accompany the memorandum.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state/regional office training coordinators within 30 days of the memorandum.
Emergency Clearance: Collection of Premium Credit Data Related to COVID-19 Emergency
On August 17, 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 “Collection of Premium Credit Data Related to COVID-19 Emergency.” CMS is requesting emergency clearance due to the agencies inability to update CMS systems for IRS reporting purposes in time for tax season if normal non-emergency clearance procedures are followed. Upon OMB approval of the emergency clearance request, CMS plans to seek public comments during required 60-day and 30-day notice and comment periods.
Comments on the emergency clearance request are due by August 24, 2020.
Enhancing RN Supervision of Hospice Aide Services
On August 17, CMS published an MLN Fact Sheet regarding RN supervisory visits. The fact sheet discusses the role of an RN responsible for supervision, the 14-day onsite RN supervisory visit, the annual onsite RN supervisory visit, and appropriate documentation of these services.
NCA for Home Use of Oxygen and Home Oxygen Use to Treat Cluster Headaches
On August 17, CMS published a Tracking Sheet regarding a national coverage analysis (NCA) to determine whether the current coverage of oxygen in the home, including home use of oxygen for cluster headaches, is reasonable and necessary under the Medicare program. CMS currently covers home oxygen for specific conditions under NCD 240.2, and it covers home oxygen use to treat cluster headaches through coverage with evidence development under NCD 240.2.2. CMS stated that in addition to the formal request to review coverage, the COVID-19 pandemic showed that a review of NCD 240.2 is necessary to ensure patient access to oxygen as needed in both the current environment and during any future public health emergencies.
Comments on the NCA are due by September 16, 2020.
Opioid Use in Medicare Part D Continued to Decline in 2019, but Vigilance is Needed as COVID-19 Raises New Concerns
On August 17, the OIG published a Data Brief regarding opioid use in Medicare Part D in 2019, which the OIG plans to use both to understand trends in opioid use and to serve as a comparison point for a future OIG data brief examining changes in opioid use that occurred during the 2020 COVID-19 pandemic. The OIG found that the number of beneficiaries receiving opioids (one in four) and the amount of spending on opioids in Part D ($2.8 billion) decreased in 2019, but the number of beneficiaries receiving drugs for medication-assisted treatment for opioid use disorder and the number of beneficiaries receiving prescriptions for naloxone continues to grow. The OIG concludes that while opioid use has decreased and the use of treatments has increased, it is crucial to remain vigilant, as the COVID-19 pandemic could be particularly dangerous for individuals with opioid use disorder and early reports for 2020 show overdose deaths may be rising in some areas of the country.
Medicare Part B Drug Payments: Impact of Price Substitutions Based on 2018 Average Sales Price
On August 17, the OIG published a Review on the impact of the price substitutions when Part B drugs have an average sales price (ASP) greater than 5% of the average manufacturer prices (AMP). When the OIG finds the ASP exceeds the AMP by this margin, it directs HHS to substitute the ASP-based payment amount with a lower calculated rate. In 2018, CMS applied this price substitution policy to 16 drugs, which resulted in $4.4 million in savings for that year. As it recommended last year, the OIG stated that if CMS applied this policy to drugs whose ASP exceeded the AMP by 5% in a single quarter, CMS could have saved an additional $1.7 million. The OIG therefore recommends CMS expand its price substitution criteria or consider other approaches to expanding the price-substitution policy that would be designed to capture more drugs that repeatedly exceed the threshold.
Comparison of Average Sales Prices (ASP) and Average Manufacturer Prices: Results for the First Quarter of 2020
On August 17, the OIG published a Report regarding drugs for which the ASP exceeds the AMP by 5% or more for two consecutive quarters or three of the previous four quarters. When this happens, CMS substitutes 103% of the AMP for the ASP-based reimbursement. In the first quarter of 2020, eight drug codes met this price substitution criteria. The OIG will provide these results to CMS for review.
Updated OIG Work Plan
On August 17, the OIG updated its Work Plan with the following new items:
- Swing-Bed Services at Nationwide Critical Access Hospitals
- Rates of Estimated Payments from Chart Reviews and Health Risk Assessments Across Medicare Advantage Organizations
- Accuracy of Nursing Home Compare Website’s Reported Health, Fire Safety, and Emergency Preparedness Deficiencies
Medicare Home Health Agency Provider Compliance Audit: Mission Home Health of San Diego, Inc.
On August 18, the OIG published a Review of whether Mission Home Health of San Diego, Inc., complied with Medicare requirements for billing home health services. The OIG found that Mission billed Medicare incorrectly for 32 of the 100 home health claims reviewed. These issues pertained to services provided to beneficiaries who did not require skilled services, services provided to beneficiaries who were not homebound, incorrect payment codes, or claims for which documentation was inadequate to support the services provided. The OIG estimated that Mission received overpayments of at least $5.9 million for the audit period.
The OIG recommends Mission refund Medicare for the identified overpayments, identify and return any similar overpayments, and strengthen its procedures to ensure correct billing of Medicare claims. Mission stated that it disputed nearly all OIG findings and did not concur with recommendations. Mission hired a consultant to review most of the claims in question and challenged the independent medical review contractor’s decisions, as the consultant said nearly all sampled claims were billed correctly. The OIG conducted an additional medical review and revised some findings related to homebound status and skilled service, lowering the number of sampled claims that were incorrectly billed from 38 down to 32. The OIG maintains the remainder of its findings are valid.
Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update FY 2021
On August 19, CMS published Medicare Claims Processing Transmittal 10314, which rescinds and replaces Transmittal 10202, dated July 2, 2020, to update the policy section by adding instructions regarding changes to the Provider Specific File and required MAC actions related to those changes as well as to correct the reference citation to the Claims Processing Manual from Chapter 6, Section 30.7 to Chapter 6, Section 30.5. The correction also adds business requirement 11859.2 to the instructions. The original transmittal was issued regarding the annual update to the payment rates for the SNF PPS.
CMS revised MLN Matters 11859 on the same date to accompany the transmittal.
Effective date: October 1, 2020
Implementation date: October 5, 2020
Emergency Declaration Blanket Waivers for Health Care Providers
On August 20, CMS updated the Fact Sheet providing the list of blanket waivers for health care providers during the COVID-19 PHE. Changes are highlighted with a red notation and include a postponement of the deadline to submit an application to the Medicare Geographic Classification Review Board for FY 2022 reclassifications. The deadline has been changed to 15 days after the public display of the FY 2021 IPPS/LTCH final rule.
CMS continues to update this document, and organizations should review regularly for any changes.
Updated Fraud Risk Indicator
On August 20, the OIG updated its Fraud Risk Indicator list with a new party in the high risk category after the entity refused to enter a Corporate Integrity Agreement sufficient to protect federal healthcare programs. The new entity is MJHS Hospice and Palliative Care, Inc., of New York.
Updated Corporate Integrity Agreement Documents
On August 21, the OIG published information on a new Corporate Integrity Agreement with Shreveport Prosthetics, Inc., of Shreveport, LA.
Advisory Panel on Hospital Outpatient Payment (HOP) Attendee Meeting Registration and Teleconference Information
On August 21, CMS published a Download Link on its HOP Panel webpage to provide attendee meeting registration and audio teleconference information for the HOP Panel meeting, which will be held on August 31.
Comment Request: Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging Services; more
On August 21, CMS published a Comment Request in the Federal Register regarding the following information collections:
- Generic Clearance for Evaluation of Stakeholder Training-Health Insurance Marketplace and Market Stabilization Programs
- Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging Services
Comments are due by October 20, 2020.
Comment Request: Generic Social Marketing & Consumer Testing Research
On August 21, CMS published a Comment Request in the Federal Register regarding an information collection titled “Generic Social Marketing & Consumer Testing Research.”
Comments on the information collection are due by October 20.
New State Payment of Medicare Premiums
On August 21, CMS published State Payment of Medicare Premiums Transmittal 4 regarding significant revisions to the entire manual to reflect current statute, regulation, operations, and systems changes that have evolved over time. The revisions are part of CMS’ Better Care for Dual Eligible Individuals Strategic Initiative.
Effective date: September 8, 2020
Implementation date: September 8, 2020
Updates to Nursing and Allied Health Education Medicare Advantage Payment Policies
On August 21, CMS published One-Time Notification Transmittal 10315 regarding instructions to MACs on how to compute and/or reconcile Medicare Advantage payments for allied health education. CMS last issued guidance to MACs on this topic in 2003 for CY 2001 nursing and allied health Medicare+Choice payments (the former name for Medicare Advantage). This transmittal provides information for CYs 2002 through 2018.
Effective date: September 21, 2020
Implementation date: November 23, 2020
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for FY 2021
On August 21, CMS published Medicare Claims Processing Transmittal 10312 regarding changes required as part of the 2021 IPF PPS final rule. These include the market basket and wage index update, changes to the IPF Quality Reporting Program, Pricer updates, Provider Specific File updates, and more.
Effective date: October 1, 2020
Implementation date: October 5, 2020
Intravenous Immune Globulin (IVIG) Demonstration: Ending December 31, 2020
On August 21, CMS published Demonstrations Transmittal 10307 regarding the end of the IVIG Demonstration on December 31, 2020. There will be no payment for the IVIG code for dates of service after December 31.
Effective date: January 1, 2021 - Demonstration ends on December 31, 2020
Implementation date: January 4, 2021
Update to ICD-10-CM for Vaping Related Disorder and Diagnosis and Procedure Codes for COVID-19
On August 21, CMS published One-Time Notification Transmittal 10317, which rescinds and replaces Transmittal 10029, dated April 1, 2020, to update the title, background section, and business requirement 11623.1 to include new procedure codes in Version 37.2 of the ICD-10 MS-DRG Grouper and ICD-10 Medicare Code Editor. The original transmittal was issued regarding a new ICD-10-CM code for vaping related disorder and was later updated to add the new ICD-10-CM code for COVID-19.
CMS revised MLN Matters 11623 on the same date to accompany the transmittal.
Effective date: April 1, 2020 - For vaping-related and COVID-19 related diagnosis codes included in V37.1 of the MS-DRG Grouper and MCE; August 1, 2020 - For new procedure codes included in V37.2 of the MS-DRG Grouper and MCE
Implementation date: April 6, 2020
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
On August 21, CMS published Medicare Claims Processing Transmittal 10318, which rescinds and replaces Transmittal 10265, dated August 7, 2020, to revise the policy section to include additional COVID-19 codes 86408, 86409, 0225U and 0226U.
On August 10, CMS published MLN Matters 11937 to accompany the transmittal.
Effective date: October 1, 2020
Implementation date: October 5, 2020
Revision to the Cost Report Acceptability Checklists
On August 21, CMS published One-Time Notification Transmittal 10316 regarding revisions to the cost report acceptability checklists to remove the post-acceptability instructions, include new documentation submission requirements, and include steps relating to the Medicare cost report electronic filing system. This will allow the checklist to be a public document because it will no longer include confidential information. The previous post-acceptability checklist instructions will now be an independent set of instructions titled “Modified Desk Review.”
Effective date: Cost reports received on or after December 31, 2020
Implementation date: Cost reports received on or after December 31, 2020