This week in Medicare updates—8/7/2019
2020 Outpatient Prospective Payment System (OPPS)/Ambulatory Surgical Center (ASC) PPS Proposed Rule
On July 29, CMS published a draft version of the 2020 OPPS/ASC Proposed Rule, which is scheduled to be published in the Federal Register on August 9. CMS is proposing to update the OPPS payment rates in 2020 by 2.7%. Some of the other proposals in the rule include:
- Increased price transparency requirements for hospitals following an executive order on price transparency. Among the proposals are a possible enforcement mechanism to penalize facilities who do not comply with price transparency policies, definitions for terms such as “standard charges” and “hospital items and services,” a requirement to make public a limited list of consumer-friendly standard charges for “shoppable” services, and more.
- Further reductions in payment for clinic visits reported by HCPCS code G0463 that are furnished in excepted off-campus provider-based departments.
- Providing a one-year exemption for procedures removed from the inpatient-only list under the OPPS from BFCC-QIO referrals to RACs for review
The rule also contained several proposals for ASCs, including:
- Updating ASC rates for 2020 by 2.7%
- Adding total knee arthroplasty, mosaicplasty, and three coronary intervention procedures to the ASC covered procedures list
- Adding one claims-based measure to the quality reporting program for 2024 payment
- Soliciting comments on potential future updates to the submission method for certain patient safety measures
CMS is also soliciting comments on the reduction in reimbursement for drugs acquired through the 340B program. A district court ruled that CMS’ reduction in reimbursement from average sales price (ASP) plus 6% to ASP minus 22.5% for these drugs was unlawful. Although CMS is appealing that ruling, it is seeking comments on how to remedy the cuts that were made up to this date should CMS lose on appeal. It is also seeking comments as to whether reimbursement at ASP plus 3% would be more appropriate for these drugs going forward.
CMS published a Press Release and Fact Sheet on the proposed rule. Comments are due no later than 5 p.m. on September 27, 2019.
2020 Medicare Physician Fee Schedule Proposed Rule
On July 29, CMS published a draft version of the 2020 Physician Fee Schedule (PFS) Proposed Rule, which is scheduled to be published in the Federal Register on August 14. CMS proposes raising the PFS conversion factor to $36.09 for 2020, a five-cent increase over the 2019 level. Some of the other proposals in the rule include:
- Aligning most of its policy for evaluation and management (E/M) codes with the recommendations from the AMA’s CPT Editorial Panel. This would include separate payment for each level of CPT codes in 2021 rather than consolidating payment to a single amount for levels 2 through 4. It would also revise E/M documentation guidelines by allowing providers to select services based on medical decision-making or time and not having them factor in history and exam elements.
- Modifying documentation policies so physicians and other practitioners can review and verify documentation rather than re-documenting notes made in the medical record by other physicians, residents, nurses, students, or members of the medical team.
- Introducing a set of Medicare-developed G codes for reporting chronic care management services in a manner that allows clinicians to bill incrementally to reflect additional time and resources required in certain cases.
- Creating new bundled payments for care for management and counseling of opioid use disorders.
CMS is also seeking comment on potentially aligning the Medicare Shared Savings Program quality performance scoring methodology more closely with the methodology for MIPS.
CMS published a Fact Sheet on the proposed rule on the same date. Comments are due no later than 5 p.m. on September 27.
2020 End Stage Renal Disease (ESRD) PPS and Durable Medical Equipment (DME) Proposed Rule
On July 29, CMS published a draft version of the 2020 ESRD PPS and DME Proposed Rule, which is due to be published in the Federal Register on August 6. CMS is proposing to update the ESRD PPS base rate to $240.27. Some of the other proposals in the rule include:
- Providing a transitional add-on payment adjustment for two years for new (granted marketing authorization by the FDA on or after January 1, 2020) and innovative (meeting substantial clinical improvement similar to that used for IPPS’ NTAP) equipment and supplies that is based on 65% of the price established by MACs.
- Halting application of the transitional drug add-on payment adjustment (TDAPA) for new renal dialysis drugs or biological products if CMS does not receive a full calendar quarter of ASP data within a certain time frame.
- Revising the drug designation process regulation for new renal dialysis drugs and biologicals that fall within an existing ESRD PPS functional category.
- Creating a new methodology for calculating fee schedule payment amounts for new DMEPOS items and services.
- Developing a new list of DMEPOS items potentially subject to face-to-face encounters, written orders prior to delivery, and/or prior authorization requirements.
CMS is also soliciting comment on a number of topics, including data collection resulting from the ESRD PPS technical expert panel, changing the basis for the ESRD PPS wage index, and new requirements for competitive bidding of diabetic testing strips.
CMS published a Fact Sheet and Press Release on the proposed rule on the same date. Comments are due by September 27, 2019.
Skilled Nursing Facility 3-Day Rule Billing
On July 29, CMS published an MLN Fact Sheet regarding the background of the 3-day rule for SNF admission and how to properly apply and bill for it. The fact sheet discusses the relationship between observation services and the rule, claims processing edits to verify SNF claims meet the 3-day rule, financial responsibility for SNF services when there is no 3-day qualifying stay, and more.
Provider Compliance Tips for Respiratory Assistive Devices
On July 29, CMS published an MLN Fact Sheet regarding compliance tips for physicians and non-physician practitioners who write requisitions or orders for respiratory assistive devices (RAD). During the 2018 reporting period, the improper payment rate for RADs was 48.4%, which represents a projected $37.9 million in improper payments. Approximately 91% of these payments were deemed improper due to insufficient documentation. The fact sheet reviews what information must be documented in orders for these devices and current Medicare coverage standards.
Ambulance Fee Schedule and Medicare Transports
On July 29, CMS published an MLN Booklet regarding coverage requirements under the ambulance transport benefit. The booklet reviews coverage standards and destinations for ground and air ambulance transport, and it provides a table showing the billing guidelines for various transport scenarios.
Updated Stipulated Penalties and Exclusion for Material Breach
On July 29, the OIG updated its list of Stipulated Penalties and Exclusion for Material Breaches with one new action:
- On July 23, Hospice of Kona paid a stipulated penalty of $9500 for failing to timely comply with certain integrity agreement requirements by not appointing a compliance officer, not posting a noticing with the name and phone number of the compliance office along with the HHS OIG Fraud Hotline number, not engaging and IRO, and not submitting its implementation report.
Updated Corporate Integrity Agreement Documents
On July 29, the OIG published information on a new Corporate Integrity Agreement with Eagleville Hospital, of Eagleville, PA.
2020 Medicare Advantage Ratebook and Prescription Drug Rate Information
On July 30, CMS published a Press Release regarding the 2020 Medicare Advantage Ratebook and Prescription Drug Rate Information. The Part D national average monthly bid amount for 2020 is $47.59 and the 2020 Part D base premium is $32.74. CMS also published the 2020 Medicare Advantage Rate Book, rate calculation data, regional rates and benchmarks, and regional PPO EGWP rates on the Medicare Advantage Rates and Statistics webpage.
2020 Inpatient Psychiatric Facilities Final Rule
On July 30, CMS published a draft version of the 2020 Inpatient Psychiatric Facility (IPF) Final Rule, which is scheduled to be published in the Federal Register on August 6. The rule updates total IPF payments by 1.5%, revises and rebases the IPF market basket to reflect a 2016 base year (rather than a 2012 base year), removes the one-year lag of wage index data to enhance consistency of wage indexes across settings, and adopts one new claims-based measure beginning with the 2021 payment determination (Medication Continuation Following Inpatient Psychiatric Discharge).
CMS published a Fact Sheet on the rule on the same date. These regulations are effective on October 1, 2019.
2020 Skilled Nursing Facility (SNF) PPS Final Rule
On July 30, CMS published a draft version of the SNF PPS Final Rule, which is due to be published in the Federal Register on August 7. The rule projects an increase in payments to SNFs by 2.4% for 2020, finalizes a sub-regulatory process to make non-substantive changes to the list of ICD-10 codes used to classify patients into clinical categories under the Patient Driven Payment Model (PDPM), aligns the definition of group therapy to that used in the IRF PPS (two to six patients doing the same or similar activities), and changes a handful of quality measures in the SNF quality reporting program.
CMS published a Fact Sheet on the rule on the same date. Regulations from the rule will be effective October 1, 2019.
CMS Advances MyHealthEData with New Pilot to Support Clinicians
On July 30, CMS published a Press Release regarding a new pilot program called Data at the Point of Care which will allow participating providers to access claims data through the DPC, which will be embedded in their workflow. CMS hopes this claims data will fill in information gaps to give them a more complete patient history with information such as previous diagnoses, past procedures, and medication lists. Providers who wish to participate can sign up at https://dpc.cms.gov.
Updated Civil Monetary Penalties and Affirmative Exclusions
On July 30, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions, including the following:
- On July 8, Damon Wade, Amy Wade, Unicare Ambulance, LLC, and PA Paramedics LLC d/b/a Eastern Care Ambulance, of Bensalem, PA, agreed to an exclusion from participation in all federal healthcare programs for varying periods of time due to making repeated false statements to avoid overpayment debts to the Medicare program and to hide the fact that Damon Wade’s state paramedic license had previously been suspended for his admission of forging a physician signature.
- On July 12, Smith Centers for Foot & Ankle Care, of Chicago, IL, reached a $37,688.76 settlement agreement with the OIG to resolve allegations that it employed an individual who was excluded from participating in any federal health care program.
- On July 12, Anesthesia Services, P.C. d/b/a University Pain Clinic, of Detroit, MI, reached a $44,900 settlement agreement with the OIG to resolve allegations that it received remuneration from Millenium Health in the form of point of care test cups which resulted in prohibited referrals.
- On July 18, Richard Mintz, D.O., of Dresher, PA, agreed to an exclusion from all federal health care programs for seven years due to allegations of issuing medically unnecessary prescriptions for opioids in exchange for cash which failed to meet the professionally recognized standards of care.
- On July 19, Corazon Ramirez, M.D., of Dallas, TX, reached a $171,480 settlement agreement with the OIG to resolve allegations the Ramirez paid remuneration to various physician-owners of Pine Creek Medical Center, where he was formerly CEO and COO, in the form of payments for print and billboard advertisements for the physician owners and their medical practices.
- On July 19, U.S. Pharmaceutical Corporation, of Decatur, GA, reached a $380,142.05 settlement agreement with the OIG to resolve allegations that it failed to submit timely certified monthly and quarterly AMP data for CMS.
Revisions to Appendix Q, Guidance on Immediate Jeopardy
On July 31, CMS revised a Memorandum to state survey agency directors that was originally published March 5, 2019, to reinsert language in Appendix Q of the State Operations Manual referring criminal acts to law enforcement. The memorandum was originally published regarding substantial revisions to guidance on immediate jeopardy in Appendix Q.
Effective date: Immediately. This policy should be communicated to all survey and certification staff, their managers, and the State and Regional Office training coordinators within 30 days of the memorandum.
2020 Inpatient Rehabilitation Facility (IRF) PPS Final Rule
On July 31, CMS published a draft version of the IRF PPS Final Rule, which is due to be published in the Federal Register on August 8. The rule updates IRF payment rates by an increase of 2.5%, finalizes revisions to case-mix groups based on quality data indicator items from FY 2017 and 2018, updates the relative weights and average length of stay values associated with those revised case-miix groups, finalizes use of an unweighted motor score beginning in FY 2020 to ease providers’ transition to use of quality data items for payment purposes, and amends regulations to clarify that the IRF will make the determination as to whether a physician qualifies as a rehabilitation physician.
CMS published a Fact Sheet on the final rule on the same date. Regulations from the rule are effective October 1, 2019.
2020 Hospice Payment Rate Update Final Rule
On July 31, CMS published the 2020 Hospice Payment Rate Update Final Rule, which is due to be published in the Federal Register on August 6. The rule updates hospice payment rates by 2.6% for 2020 and sets the cap amount at $29,964.78. It also finalizes modifications to the existing hospice election statement content requirements by requiring hospices to provide (upon request) an election statement addendum with a list of items, drugs and services the hospice deems to be unrelated to the terminal illness along with a rational for each. In addition, it finalizes use of the concurrent IPPS wage index for the hospice wage index to better align with other settings of care.
CMS published a Fact Sheet on the final rule on the same date. Regulations from the rule are effective October 1, 2019.
Comment Request: Hospice Survey and Deficiencies Report Form and Supporting Regulations; Recognition of Pass-Through Payment for Additional (New) Categories of Devices under the Outpatient Prospective Payment System and Supporting Regulations
On July 31, CMS published a Comment Request in the Federal Register regarding the submission for OMB review of the following information collections:
- Hospice Survey and Deficiencies Report Form and Supporting Regulations
- Recognition of Pass-Through Payment for Additional (New) Categories of Devices under the Outpatient Prospective Payment System and Supporting Regulations
Comments are due to the OMB desk officer by August 30, 2019.
Oxygen Policy Update
On July 31, CMS published One-Time Notification Transmittal 2326, which rescinds and replaces Transmittal 2124, dated August 10, 2018, to remove the sensitive/controversial disclaimer and to revise the background and policy sections. The original transmittal was issued regarding instructions for implementing a new policy and coding requirement for oxygen content.
Effective date: January 1, 2019
Implementation date: January 7, 2019
2020 Advance Beneficiary Notice of Noncoverage Form
On August 1, CMS published the 2020 Advance Beneficiary Notice of Noncoverage Forms for download. The downloads include English, Spanish, and large-print versions of the form as well as an ABN Alternative Format Sample for Labs.
Automation of Part B Underpayment Processing of Recovery Audit Contractor (RAC) Adjustments
On August 2, CMS published One-Time Notification Transmittal 2329 regarding automation of a process that will allow for RAC-identified Part B underpayments to process without manual intervention.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for FY 2020
On August 2, CMS published Medicare Claims Processing Transmittal 4353 regarding the annual update of the IRF Pricer software package. The updates include several rate changes and will utilize case-mix groups as established in the IRF PPS final rule.
Effective date: October 1, 2019
Implementation date: October 7, 2019
Instructions for Use of Informational Remittance Advice Remark Code Alert on Laboratory Service Remittance Advices
On August 2, CMS published One-Time Notification Transmittal 2335 regarding a new RARC code to include on remittance advices that will remind laboratories which meet the definition of an applicable laboratory of their data reporting obligations under PAMA.
Effective date: January 1, 2020
Implementation date: January 6, 2020
HIPAA Electronic Data Interchange (EDI) Front End Updates for January 2020
On August 2, CMS published One-Time Notification Transmittal 2332 regarding the January 2020 CCEM edits for the Part A and Part B MACs and the Common Electronic Data Interchange (CEDI) contractor.
Effective date: January 1, 2020
Implementation date: January 6, 2020
October Quarterly Update to 2019 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement
On August 2, CMS published Medicare Claims Processing Transmittal 4341 regarding updates to the list of HCPCS codes subject to consolidated billing for SNFs.
Effective date: October 1, 2019
Implementation date: October 7, 2019
Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process
On August 2, CMS published One-Time Notification Transmittal 2331 regarding a process to ensure that certain claims submitted without a required diagnosis code or incorrect Claims Adjustment Group Code (CAGC) are handled by the Part A and Home Health and Hospice MACs in a standard manner.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
On August 2, CMS published Medicare Claims Processing Transmittal 4347 regarding the quarterly update to the CLFS. This update includes three newly approved ADLTs effective July 1, 2019, and several new proprietary laboratory analyses codes.
Effective date: October 1, 2019
Implementation date: October 7, 2019
Medicare Shared Savings Program (MSSP) Skilled Nursing Facility (SNF) Affiliates’ Requirement to Include Demonstration Code 77 on SNF Waiver Claims
On August 2, CMS published One-Time Notification Transmittal 2330 regarding a waiver for the SNF 3-day rule requirement under certain circumstances in the MSSP. CMS will require SNF affiliates to include demonstration code 77 in the treatment authorization field on claims when the SNF affiliate intends for the claim to be subject to the 3-day rule waiver.
Effective date: January 1, 2020
Implementation date: January 6, 2020
2020 IPPS Final Rule
On August 2, CMS published a draft version of the 2020 IPPS and Long-Term Care Hospital (LTCH) PPS Final Rule, which is due to be published in the Federal Register on August 16. CMS is increasing the IPPS operating payment by 3.1% and increasing LTCH PPS payments overall by 1.0%. The rule finalized several policies, including:
- Increasing the wage index for hospitals with a wage index value below the 25th percentile by half the difference between the otherwise applicable wage index value for that hospital and the 25th percentile wage index value across all hospitals. The policy will be effective for at least four years beginning in FY 2020.
- CMS did not finalize a proposal that would make the policy budget neutral by decreasing the wage index for hospitals above the 75th percentile. It will instead make a budget neutrality adjustment to the standardized amount applied across all IPPS hospitals.
- Increasing the new technology add-on payment from 50% to 65% beginning in 2020
- CMS is additionally increasing the add-on payment for certain antimicrobials to 75%
- Revising and clarifying certain aspects of the way CMS evaluates “substantial clinical improvement criterion”
- Finalizing new technology add-on payments for 18 technologies, including the continuation of the new technology payment for one chimeric antigen receptor T-cell (CAR-T) therapy
For LTCHs, site neutral payment rate cases will be paid exclusively on the site neutral payment rate for LTCH discharges occurring in cost reporting periods beginning in FY 2020. Discharges paid using the LTCH PPS standard federal payment rate will increase by 2.7%, and payments for cases continuing to transition to the site-neutral payment rate will decrease by 5.9%.
CMS published a Press Release and Fact Sheet on the final rule on the same date. The rule is effective October 1, 2019.