This week in Medicare updates—9/12/2018
Guidance to Hospitals and Critical Access Hospital (CAH) Surveyors Addressing Revisions to Swing-Bed Requirements
On August 31, CMS published a Memorandum to state survey agency directors regarding updated guidance on special requirements for hospital and CAH providers of long-term care (LTC) services pertaining to swing beds. Guidance for hospitals has been moved to Appendix A of the State Operations Manual and guidance for CAHs has been revised in Appendix W to reflect the provisions of the final rule that revised requirements for LTC facilities in 2017. The CAH survey protocol has also been significantly revised.
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 this memorandum.
Home Health Agency (HHA) Interpretive Guidelines
On August 31, CMS published a Memorandum to state survey agency directors regarding the release of the final HHA Interpretive Guidelines associated with the new Conditions of Participation for HHAs that became effective January 13, 2018. Revisions will be made to Appendix B of the State Operations Manual to incorporate these new guidelines.
Effective date: Immediately. These guidelines should be communicated with all survey and certification staff, their managers, and the state/regional office training coordinators within 30 days of this memorandum.
Global Surgery Booklet
On September 4, CMS published an MLN Booklet to provide education on the global surgery package. The booklet includes information about billing and payment rules for surgeries, endoscopies, and global surgical packages split between two or more physicians.
Merit-based Incentive Payment System (MIPS) Measures and Activities By Provider Type
On September 4, CMS published MIPS resource sheets tailored to specific types of providers, including anesthesiologists, cardiologists, and radiologists. Each document describes what that specific provider type should do to participate in the four MIPS performance categories for the 2018 reporting year.
Reminder on Billing Requirements Implemented for non-OPPS Providers
On September 4, CMS published Special Edition MLN Matters 18012 regarding enforcement editing requirements for non-OPPS providers through the Correct Coding Policy and Correct Coding Initiative as discussed in CRs 10504 and 10699. The article reviews the background of the Correct Coding Initiative history, the Outpatient Code Editor (OCE) (both OPPS and non-OPPS), the Integrated Outpatient Code Editor (I/OCE), and the addition of specific edit numbers and dispositions for non-OPPS hospitals.
Effective date: April 1, 2018; July 1, 2018
Implementation date: April 2, 2018 for CR 10504 and July 2, 2018 for CR 10699
Updated Provider Self-Disclosure Settlements
On September 5, the OIG published an updated List of Provider Self-Disclosure Settlements, including:
- On August 2, Monadnock Community Hospital, of New Hampshire, reached a $76,555.18 settlement with the OIG for allegedly submitting false or fraudulent claims to Medicare for intravenous therapy for non-end stage renal disease patients with a single diagnosis of iron deficiency
- On August 2, Heart of America Medical Center, of North Dakota, reached a $76,262.06 settlement with the OIG for allegedly employing an individual it knew or should have known was excluded from participation in federal health care programs
- On August 6, Wahiawa Hospital Association and Wahiawa General Hospital reached a $100,000 settlement with the OIG for allegedly providing remuneration to a family health center by leasing office space at below fair market value
- On August 7, Digestive Health Specialists, P.A. (DHS), of North Carolina, reached a $478,668 settlement with the OIG for allegedly receiving remuneration from two anesthesia practices in the form of free nasal cannulas and anesthesia-related drugs when the practices provided anesthesia services through its employed and contracted anesthesiologists or certified nurse anesthetists at DHS’s endoscopy centers.
- On August 21, Prospect CharterCare RWMC, LLC, of Rhode Island, reached a $78,525.25 settlement with the OIG for allegedly submitting claims to Medicare for services provided at freestanding clinics when those services were billed as if they were provided at a provider-based location.
- On August 22, DeWitt Hospital and Nursing Home, of Arkansas, reached a $123,935.30 settlement with the OIG for allegedly failing to perform quarterly utilization review audits of patient charts and failing to obtain consent for care for certain patients as required to receive an all-inclusive rate for covered services provided by rural health care practitioners.
- On August 28, Adventist Health System Sunbelt Healthcare Corporation, of Florida, reached a $21,219.17 settlement with the OIG for allegedly employing an individual it knew or should have known was excluded from participation in federal health care programs.
Quarterly Influenza Virus Vaccine Code Update - January 2019
On September 5, CMS published Medicare Claims Processing Transmittal 4127, which rescinds and replaces Transmittal 4100, dated August 3, 2018, to add business requirement 10871.6.1. The original transmittal was issued to provide the quarterly update to payment and edits in the Common Working File and Fiscal Intermediary Shared System to include and update new or existing influenza virus vaccine codes.
On September 6, CMS published a revised MLN Matters 10871 to accompany the transmittal.
Effective date: January 1, 2019
Implementation date: January 7, 2019
National Correct Coding Initiative (NCCI) Add-on Codes for Non-Outpatient Prospective Payment System (OPPS) Institutional Providers Implementation
On September 6, CMS published One-Time Notification Transmittal 2137, which rescinds and replaces Transmittal 2044, dated March 16, 2018, to change “date of service” to “encounter” in the background section and business requirement 10504.1.1. The original transmittal was issued to implement NCCI add-on code edits for non-OPPS institutional providers.
Effective date: April 1, 2018
Implementation date: April 2, 2018
Annual Clotting Factor Furnishing Fee Update 2019
On September 7, CMS published Medicare Claims Processing Transmittal 4128 regarding the annual update to the clotting factor furnishing fee. The fee will be $0.220 per unit in 2019.
Effective date: January 1, 2019
Implementation date: January 7, 2019
Updated Civil Monetary Penalties and Affirmative Exclusions
On September 7, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions agreements, including:
- On August 17, an Administrative Law Judge upheld the 15-year exclusion of Karim Maghareh, Ph.D., and BestCare Laboratory Services, LLC, of Webster, Texas, due to false claims to Medicare for reimbursement of travel costs associated with sample collections when commercial airline flights were used to ship samples that were unaccompanied by trained personnel.
- On August 21, La Fuente Ocular Prosthetics, LLC, of Oklahoma City, Oklahoma, was excluded until it cures the default of its payment obligations under a settlement with the OIG for false or fraudulent claims to Medicare and false records material to a false claim.
- On August 24, St. Mary’s Health System, of Lewiston, Maine, reached a $68,497.32 settlement agreement with the OIG to resolve allegations that it employed an individual it knew or should have known was excluded from participation in any federal health care program.