This week in Medicare updates—9/18/2019

September 18, 2019
Medicare Insider

2019-2020 Influenza (Flu) Resources for Health Care Professionals

On September 9, CMS published Special Edition MLN Matters 19022 regarding resources for health care professionals relevant to the 2019-2020 flu season. It also contains a table with applicable payment allowances for HCPCS and CPT codes for different types/brands of the flu vaccine. 


CMS Could Use Comprehensive Error Rate Testing Data to Identify High-Risk Home Health Agencies

On September 10, the OIG published a Data Brief regarding a method of identifying high-risk home health agencies based on CERT data to provide CMS with a way to improve its enforcement and educational efforts toward reducing improper home health payments/error rates. The OIG used CERT data from FYs 2014-2017 and was able to identify 87 high-risk home health agencies who, in the CERT sample, had an improper payment rate of 78% and received $1 million in improper payments. The OIG concluded that CERT data can be useful in identifying high-risk home health agencies. However, CMS wrote in comments on the data brief that it does not believe the OIG’s methods for identifying these home health agencies was valid, as CERT data is not designed to be precise at the provider level. It also noted that it has attempted to use CERT data in the past to identify high-risk providers, but the data proved misleading and ineffective. The OIG maintained that the method used for this data brief was valid. 


Solutions to the MAC Prepayment Review Reports

On September 10, CMS published One-Time Notification Transmittal 2361, which rescinds and replaces Transmittal 2349, dated August 9, 2019, to update the implementation date and revise elements of the file layout attachment. The original transmittal was issued to provide solutions to errors caused by change requests 10414, 104600, and 10461 (implemented April 1, 2019) that impacted MAC prepayment review reports. 

Effective date: January 1, 2020 - Effective date shall be based on implementation date and not date of service

Implementation date: January 6, 2020


Updated Provider Self-Disclosure Settlements

On September 13, the OIG published an updated List of Provider Self-Disclosure Settlements, including:

  • On August 1, Clarity Child Guidance Center, of Texas, reached a $19,670.97 settlement agreement with the OIG to resolve allegations that it submitted claims to a federal health care program for pediatric psychotherapy services that did not meet the applicable time rules for the time-based CPT code reported.
  • On August 1, Community Physicians of Indiana, Inc., of Indiana, reached a $756,181.95 settlement agreement with the OIG to resolve allegations that it improperly submitted claims to federal health care programs with E/M CPT codes 99212, 99213, 99214, and 99215 reported with oncology infusion services codes for the same patients on the same days when there was no documentation to report each as a separate service. 
  • On August 13, The Regents of the University of California on behalf of the University of California San Diego Health System (UCSD), of California, reached a $5,315,927.49 settlement agreement with the OIG to resolve allegations that it submitted claims for hospital inpatient services that should have been billed as hospital outpatient or observation services. It also allegedly submitted claims for critical care management services when documentation did not support billing under CPT codes 99291 or 99292. 
  • On August 23, Quest Diagnostics Incorporated, on behalf of Quest Diagnostics TB, LLC, formerly known as Oxford Immunotec, Inc., reached an $88,780.74 settlement agreement with the OIG to resolve allegations that it paid remuneration in the form of collection, processing, and handling payments related to the collection of blood to physicians and physician groups. Quest acquired Oxford Immunotec on November 6, 2018, two years after the time period in which Oxford Immunotec is alleged to have violated the civil monetary penalties provision (June 1, 2011 - December 31, 2016).
  • On August 27, Leominster Dermatology, LLP, of Massachusetts, reached a $149,447.82 settlement agreement with the OIG to resolve allegations that it sought reimbursement for phototherapy services using CPT code 96910 when code 96900 was appropriate. 

The list also included multiple settlements reached after facilities self-disclosed that they employed individuals they knew or should have known were excluded from participation in federal health care programs. These facilities include: 

  • Oklahoma State University Medical Trust d/b/a Oklahoma State University Medical Center
  • Granite State Independent Living Center
  • U.S. Renal Care, Inc.


Drug Vial Size Report

On September 13, CMS published a Notice in the Federal Register to announce it is issuing a single-source funding opportunity to the National Academies of Sciences, Engineering, and Medicine to conduct a study on the federal healthcare costs, safety, and quality concerns associated with discarded drugs that results from weight-based dosing of medications contained in single dose vials. The performance period will be 18 months from the date of the award, which is issued in the amount of $1.2 million to the Academies.  


October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

On September 13, CMS published Medicare Claims Processing Transmittal 4395, which rescinds and replaces Transmittal 4331, dated July 5, 2019, to correct the file name in business requirement 11343.1.1.2. The original transmittal was issued regarding the quarterly drug pricing files for ASP and Not Otherwise Classified drugs.

On July 9, CMS published MLN Matters 11343 to accompany the transmittal.  

Effective date: October 1, 2019

Implementation date: October 7, 2019


Billing for Hospital Part B Inpatient Services

On September 13, CMS published Medicare Claims Processing Transmittal 4394 regarding billing instructions for Part B inpatient claims. It also removes revenue code 0240 from the listing of services not allowed, as it was inadvertently added to that list for these claims. 

Effective date: October 1, 2013

Implementation date: October 15, 2019


Internet Only Manual Update to Add New and Revised Sections of Pub. 100-04, Chapter 11

On September 13, CMS published Medicare Claims Processing Transmittal 4393 regarding updates to Chapter 11 of the manual. These updates include a new section on decision logic used by the pricer on claims, an instruction on reporting time increments for service units, and more. 

Effective date: November 25, 2019

Implementation date: November 25, 2019