This week in Medicare updates—9/30/2020
Medicare Payment for COVID-19 Viral Testing: Skilled Nursing Facility
On September 18, CMS published Slides that include a decision tree, payment information, and coding and billing details for COVID-19 viral testing at skilled nursing facilities/nursing facilities.
Incorrect Acute Stroke Diagnosis Codes Submitted by Traditional Medicare Providers Resulted in Millions of Dollars in Increased Payments to Medicare Advantage Organizations
On September 21, the OIG published a Review of whether select acute stroke diagnosis codes submitted by physicians under traditional Medicare and used later by CMS to make payments to Medicare Advantage (MA) organizations on behalf of transferred enrollees were compliant with federal requirements. The OIG focused this review 582 randomly selected transferred enrollees for whom a physician’s claim contained a selected acute stroke diagnosis code (mapping to Ischemic or Unspecified Stroke HCC) but a corresponding inpatient claim did not contain that code. The OIG found that medical records only supported the acute stroke diagnosis code for two of the 582 transferred enrollees reviewed, meaning the Ischemic or Unspecified Stroke HCCs were not validated. These errors were due to incorrect coding but went unnoticed and subsequently caused inaccurate payments in MA because CMS did not have policies/procedures in place to identify beneficiaries who transferred from traditional Medicare to MA and CMS did not evaluate whether the codes for these transferred enrollees complied with federal requirements. The OIG estimates CMS made inaccurate payments of just over $14.4 million to MA organizations for cases like these.
The OIG recommends CMS educate physicians on correct submission of acute stroke diagnosis codes and how those codes impact the MA program. It also recommends CMS develop and implement policies and procedures to prevent issues like this from happening in the future. CMS concurred with OIG recommendations and described actions it has taken or plans to take to address them.
Illinois Should Improve Its Oversight of Selected Nursing Homes’ Compliance with Federal Requirements for Life Safety and Emergency Preparedness
On September 21, the OIG published a Review of whether Illinois ensured that certain nursing homes who participated in either Medicare or Medicaid complied with CMS requirements for life safety and emergency preparedness. The review was conducted based on unannounced site visits at 15 nursing homes from October through December 2018. The OIG found deficiencies at all 15 nursing homes (53 instances of noncompliance with life safety requirements and 184 instances of noncompliance with emergency preparedness), which shows Illinois did not ensure that nursing homes were compliant with CMS requirements for life safety and emergency preparedness. This occurred because Illinois’s existing life safety training program could not educate all Illinois nursing homes in a timely manner and the state didn’t offer an emergency preparedness training program for nursing home management. The state performed abbreviated surveys of emergency preparedness plans, had insufficient personnel for the survey workload, and did not determine whether carbon monoxide alarms were installed according to state law.
The OIG recommends Illinois follow up with the deficient nursing homes to verify corrective actions have been taken, conduct more thorough emergency preparedness reviews, work with CMS to develop emergency preparedness training and expand life safety training, consider increasing staffing levels for state surveyors, and consider modifying survey procedures to properly check carbon monoxide alarms. Illinois generally agreed with the findings but noted some challenges to implementing the recommendations.
Updated OIG Work Plan
On September 21, the OIG updated its Work Plan with the following new items:
- COVID-19 Testing Data from Federal Programs
- Infection Control at Home Health Agencies During the COVID-19 Pandemic
- HHS and ASPR Actions Related to Resources, Supplies, and Treatments Needed to Address COVID-19
North Carolina Should Improve Its Oversight of Selected Nursing Homes’ Compliance with Federal Requirements for Life Safety and Emergency Preparedness
On September 22, the OIG published a Review of whether North Carolina ensured that certain nursing homes who participated in either Medicare or Medicaid complied with CMS requirements for life safety and emergency preparedness. The review was conducted based on unannounced site visits at 20 nursing homes from December 2018 through May 2019. The OIG found deficiencies at 18 of the 20 nursing homes reviewed (64 instances of noncompliance with life safety requirements and 124 instances of noncompliance with emergency preparedness), which shows North Carolina did not ensure that nursing homes were compliant with CMS requirements for life safety and emergency preparedness. This occurred because nursing homes had inadequate management and high staff turnover. North Carolina did not have a standard life safety training program for all nursing home staff and generally only performed life safety surveys once every 8 to 15 months even at higher risk nursing homes.
The OIG recommends North Carolina follow up with the deficient nursing homes to verify corrective actions have been taken, work with CMS to develop life safety training for nursing home staff, and conduct more frequent surveys at nursing homes with a history of multiple high-risk deficiencies. North Carolina agreed with some recommendations but expressed concerns about life safety and emergency preparedness findings, the timing of the surveys, and the qualifications of auditors performing the life safety survey. The OIG removed a deficiency related to emergency water supplies after reviewing North Carolina’s comments.
CMS to Expand Successful Ambulance Program Integrity Payment Model Nationwide
On September 22, CMS published a Press Release to announce that it will expand the Medicare Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) nationwide. The Second Interim Evaluation Report on the model, published on the same date, found that the model reduced RSNAT service use by 63% and reduced RSNAT expenditures by 72% among beneficiaries with end-stage renal disease and/or severe pressure ulcers. The model will continue in the currently participating states (D.C., Delaware, Maryland, New Jersey, North Carolina, South Carolina, Pennsylvania, Virginia, and West Virginia) beyond December 1, 2020, when the model was originally scheduled to end. It will be introduced nationwide at a time to be determined later given the current COVID-19 PHE.
Advisory Opinion 20-05
On September 23, the OIG published an Advisory Opinion regarding a pharmaceutical manufacturer’s proposal to provide cost-sharing assistance directly to Medicare beneficiaries who are prescribed either of two formulations of its drug. The requestor asks whether this arrangement constitutes grounds for the imposition of sanctions due to a prohibition on inducements to beneficiaries or under provisions related to the federal anti-kickback statute. The drug would be used to treat a condition which is a progressive, rare disease that can lead to heart failure and death. While the medications are not curative, they have reduced all-cause mortality, frequency of hospitalizations, and reduced the decline in functional capacity and quality of life in clinical trials. Alternative treatments are limited. The drug, which was the most expensive cardiovascular drug ever introduced in the United States according to a 2020 report, would cost beneficiaries approximately $13,000 out of pocket annually, making it cost-prohibitive. The OIG also stated that it has concerns that the proposed arrangement and the extreme list price of the drug ($225,000 per year) could potentially drive up costs to Medicare and believe there is a significant risk that the arrangement could be used to support future increases in the list price.
The OIG concluded that the proposed arrangement would not generate prohibited remuneration under the civil monetary provision prohibiting inducements to beneficiaries but would generate prohibited remuneration under the anti-kickback statute if the requisite intent was present to induce or reward referrals for, or purchases of, items and services reimbursable by federal health care programs. The OIG could potentially impose administrative sanctions in connection with this, but any definitive conclusion on that would require the arrangement to be implemented. Because the arrangement is currently only proposed, the OIG cannot reach a definitive conclusion regarding the existence of an anti-kickback violation.
October 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
On September 23, CMS published Medicare Claims Processing Transmittal 10366, which rescinds and replaces Transmittal 10348, dated September 11, to revise HCPCS code C9066 in table 2 of the attachment.
On September 24, CMS revised MLN Matters 11963 to accompany the transmittal.
Effective date: October 1, 2020
Implementation date: October 5, 2020
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
On September 24, CMS published Medicare Claims Processing Transmittal 10367, which rescinds and replaces Transmittal 10318, dated August 21, 2020, to add a new COVID-19 code (86413) and ADLT code (0090U) to the policy section and revise business requirement 11937.2.1 The original transmittal was issued regarding the quarterly update to the CLFS.
On September 24, CMS revised MLN Matters 11937 to accompany the transmittal.
Effective date: October 1, 2020
Implementation date: October 5, 2020
Penalty for Delayed Request for Anticipated Payment (RAP) Submission--Implementation
On September 24, CMS published Medicare Claims Processing Transmittal 10396, which rescinds and replaces Transmittal 10254, dated July 31, 2020, to revise service date reporting instructions in Chapter 10, section 40.1 and instructions for remarks in section 40.2. The original transmittal was issued regarding implementation of policies for the Home Health Prospective Payment System related to RAPS.
CMS published MLN Matters 11855 on the same date to accompany the transmittal.
Effective date: January 1, 2021
Implementation date: January 4, 2021
Change to the Payment of Allogeneic Stem Cell Acquisition Services
On September 24, CMS published Medicare Claims Processing Transmittal 10371, which rescinds and replaces Transmittal 10218, dated July 10, 2020, to remove ‘standard’ from the definition of Pass-Through Amount for Allogeneic Stem Cell Acquisition in the Provider Specific File in the attachment and in business requirement 11729.1. The original transmittal was issued regarding changes to the claims processing system to prepare it to pay for allogeneic stem cell acquisition services on a reasonable cost basis.
On September 24, CMS revised MLN Matters 11729 to accompany the transmittal.
Effective date: For cost reporting periods beginning on or October 1, 2020
Implementation date: October 5, 2020 - Analysis and Design; January 4, 2021 - Design, Coding, and Testing
October 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
On September 24, CMS published Medicare Claims Processing Transmittal 10373, which rescinds and replaces Transmittal 10331, dated August 28, 2020, to add new section I.B.2. "New Category I CPT code 99072 for Reporting of Additional Practice Expenses Incurred During a Public Health Emergency (PHE), Including Supplies and Additional Clinical Staff Time". Changes also include new COVID-19 CPT code, 86413, in table 1, attachment A, and a new table 2 with the new 99072 CPT code. CMS re-numbered all sections after section 1 in the policy section I.B.; all tables following table 1 in the Attachment A; and all subsections following a new subsection e. in section I.B.8 "Drugs, Biologicals, and radiopharmaceuticals.” New table 12 was added to Attachment A to describe changes in subsection e. Section I.B.g was updated to reflect the change to the long descriptor for HCPCS, C9066. Table 14 in the attachment A was also updated to reflect this change. Tables 8 and 12 in the Attachment A were updated as well to reflect the correct long descriptor for C9066. The original transmittal was issued regarding the October 2020 update of the OPPS.
Effective date: October 1, 2020
Implementation date: October 5, 2020
FY 2021 Updates to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer
On September 24, CMS published Medicare Claims Processing Transmittal 10372, which rescinds and replaces Transmittal 10338, dated August 27, 2020, to revise the hourly CHC rate on the Hospice Table attachment. The original transmittal was issued regarding updates to the hospice payments rates, hospice wage index, and pricer for FY 2021.
On September 24, CMS revised MLN Matters 11876 to accompany the transmittal.
Effective date: October 1, 2020
Implementation date: October 5, 2020
CMS’ Monitoring Activities for Ensuring That Medicare Accountable Care Organizations (ACO) Report Complete and Accurate Data on Quality Measures Were Generally Effective
On September 24, the OIG published a Review on whether CMS’ monitoring activities were effective for ensuring that ACOs report complete and accurate data on quality measures. The OIG found CMS’ monitoring activities were generally effective for ACOs reporting data on quality measures through claims, administrative data, and the CMS web portal. However, the OIG identified weaknesses with CMS’ monitoring activities for ACOs reporting through the patient survey. CMS did not ensure that its contractor verified survey vendors’ correction of identified issues with collection of/reporting of data, reviewed survey instruments translated into other languages, and CMS did not ensure the contractor provided feedback reports in time for survey vendors to include all changes implemented in Quality Assurance Plans.
The OIG recommends CMS update the statement of work to require the contractor to verify survey vendors have corrected identified issues, confirm all implemented changes to address identified issues are included in QAPs, and review translated survey tools to ensure consistency with the English version. CMS concurred with the OIG’s recommendations.
Updated Corporate Integrity Agreement Documents
On September 24, the OIG published information on new Corporate Integrity Agreements with the following organizations:
- Williamsburg Physical Therapy, P.C., First Plus Service, Inc., Euro Physical Therapy, P.C., Alex Klurfeld and Diana Klurfeld, of Brooklyn, NY
- Mora Eye Clinic and David S. Mora, O.D., of Laredo, TX
- Progenity, Inc., of San Diego, CA
- Kelly, William M., M.D., Inc., and Omega Imaging, Inc., of Palm Desert, CA
Comment Request: 1915(c) Home and Community Based Services (HCBS) Waiver Application; Medicare Program: Conditions for Payment of Power Mobility Devices, including Power Wheelchairs and Power-Operated Vehicles; more
On September 24, CMS published a Comment Request in the Federal Register regarding the submission for OMB review of the following information collections:
- 1915(c) Home and Community Based Services (HCBS) Waiver Application
- QIC Demonstration Evaluation Contractor (QDEC): Analyze Medicare Appeals to Conduct Formal Discussions and Reopenings with DME Suppliers and Part A Providers
- Medicare Program: Conditions for Payment of Power Mobility Devices, including Power Wheelchairs and Power-Operated Vehicles
- State Medicaid Eligibility Quality Control Sample Selection Lists
- Quality Improvement Strategy Implementation Plan, Progress Report Form and Modification Summary Supplement
Comments are due to the OMB desk officer by October 26.
Comment Request: Request for Retirement Benefit Information; Application for Enrollment in Medicare the Medical Insurance Program; more
On September 24, CMS published a Comment Request in the Federal Register regarding the following information collections:
- Application for Health Insurance Benefits Under Medicare for Individual with Chronic Renal Disease and Supporting Regulations in 42 CFR
- Application for Enrollment in Medicare the Medical Insurance Program
- Request for Retirement Benefit Information
- Certification Statement for Electronic File Interchange Organizations (EFIOs) that submit National Provider Identifier (NPI) data to the National Plan and Provider Enumeration System (NPPES)
Comments are due by November 23.
2021 Benefit and Cost-Sharing Information for Medicare Advantage and Part D Prescription Drug Plans
On September 24, CMS published a Press Release to announce the cost-sharing and benefit information for the 2021 Medicare Advantage and Part D Prescription Drug Plans ahead of the start of open enrollment, which will begin on October 15. The average monthly plan premium for Medicare Advantage is expected to decrease by 11% from 2020, as the 2020 average monthly premium was $23.63 and the average 2021 monthly premium will be an estimated $21.00. This is the lowest average monthly premium since 2007. CMS expects Medicare Advantage enrollment to increase to 26.9 million beneficiaries. Over 94% of Medicare Advantage will offer additional telehealth benefits in 2021, a significant increase from the 2020 mark of 58% of Medicare Advantage plans offering additional telehealth benefits. There are also over 1,600 Medicare Advantage and Part D plans offering insulin at no more than $35 per month beginning in January 2021.
CMS published a Chart on Medicare Advantage premium changes, a variety of Download Links with information on premiums and costs for 2021 Medicare Advantage and Part D plans, a Fact Sheet on the Medicare Advantage Value-Based Insurance Design Model CY 2021 Model Participation, and State-by-State Information on Medicare Advantage and Part D plans on the same date.
Updated Detailed Notice of Discharge Form
On September 25, CMS published an updated Download Link for the Detailed Notice of Discharge forms in both English and Spanish. The folder contains an update to the English version of the form from August 2020.
CMS Releases New Tools to Streamline Certification for Labs Testing for COVID-19
On September 25, CMS published a Press Release to announce new tools available for labs seeking CLIA certification to test for COVID-19. This includes a Quick-Start Guide to help labs with the application process. The guide also includes information on the expedited review process that allows labs to start COVID-19 testing before the official paper certificate for CLIA arrives in the mail. Labs can also now pay CLIA certification fees on the CMS CLIA Program website.
States Continue to Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018
On September 25, the OIG published a Report on the extent to which state survey agencies met required timeframes for investigating the most serious nursing home complaints from 2016-2018. The OIG found that the rate of nursing home complaints per 1000 nursing home residents rose from 45 in 2015 to 52 in 2018. It also noted that 21 states failed to meet CMS’ timeliness threshold in all three years included in the report, and 10 of these same states failed to meet the timeliness threshold for eight consecutive years from 2011-2018. The OIG checked in on five states that had been identified as states who fell short in 2011-2015 and found that four of those states (Arizona, Maryland, New York, Tennessee) continued to fall short in 2016-2018 while one state (Georgia) showed limited improvement. Trends in 2016-2018 raised new concerns about New Jersey, Illinois, and Texas. The OIG recommends CMS ensure all states receive training on updated triage guidance for triaging complaints. It also recommends CMS identify new approaches to address states who consistently fail to meet required timeframes for investigating the most serious nursing home complaints.
Approval of the Application by the Community Health Accreditation Partner for Initial CMS Approval of its Home Infusion Therapy Accreditation Program
On September 25, CMS published a Final Notice in the Federal Register to announce it has approved the Community Health Accreditation Partner (CHAP) for initial recognition as a national accrediting organization for home infusion therapy suppliers that wish to participate in Medicare.
Dates: The approval announced in this final notice is effective September 25, 2020 through September 25, 2024.
New Physician Specialty Code for Micrographic Dermatologic Surgery (MDS) and Adult Congenital Heart Disease (ACHD) and a New Supplier Specialty Code for Home Infusion Therapy Services
On September 25, CMS published Medicare Claims Processing Transmittal 10374 and Medicare Financial Management Transmittal 10374, which rescinds and replaces Claims Processing Transmittal 10124 and Financial Management Transmittal 10124, dated May 8, 2020, to revise business requirement 11750-04.7 to remove specialty code D6. The original transmittal was issued regarding a new physician specialty code for MDS (D7) and ACHD (D8) as primary or secondary specialty codes and a new supplier specialty code for home infusion therapy services (D6).
On September 25, CMS revised MLN Matters 11750 to accompany the transmittals.
Effective date: October 1, 2020
Implementation date: October 5, 2020
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 27.0, Effective January 1, 2021
On September 25, CMS published Medicare Claims Processing Transmittal 10364 regarding the normal quarterly update to the NCCI PTP edits.
Effective date: January 1, 2021
Implementation date: January 4, 2021