This week in Medicare updates – 12/6/2017

December 6, 2017
Medicare Insider

Payment Reduction for X-Rays Taken Using Computed Radiography

On November 21, CMS published Medicare Claims Processing Transmittal 3820 regarding the implementation of a provision in the Social Security Act reducing payment for X-rays taken during CYs 2018-2022 using computed radiography. Beginning January 1, 2018, payment for the technical component of these services will be reduced by 7%. Claims for these services must include modifier -FY to signify the applicable payment reduction.   

On November 28, CMS published MLN Matters 10188 to accompany Transmittal 3820.

Effective date: January 1, 2018

Implementation date: January 2, 2018


2018 Payment Update for IVIG Demonstration

On November 22, CMS published Demonstrations Transmittal 186, which rescinds and replaces Demonstrations Transmittal 185, dated November 3, 2017, to change a date in the background section of the change request from December 31, 2010 to December 31, 2020. The original transmittal pertains to updates to the payment rate for the IVIG demonstration and extensions to the IVIG demonstration program. Current payment rates can continue through December 31, 2017. The change request specifies the new payment rates effective January 1, 2018. In addition, all claim editing in place prior to October 1, 2017 should continue on/after October 1, 2017.

On November 22, CMS revised MLN Matters 10343, which accompanied the original transmittal, to reflect the changes to the date in the background section.

Effective date: October 1, 2017

Implementation date: January 2, 2018


Weekly Enrollment Snapshot for Weeks 3, 4

On November 22, CMS published a Fact Sheet regarding the third week of 2018 Open Enrollment. The week covered the period from November 12 through November 18 and saw 798,829 enrollees select plans for 2018.

On November 29, CMS published a Fact Sheet regarding the fourth week of 2018 Open Enrollment (November 19-25). There were 504,181 people who selected plans in week four. Through the first four weeks of 2018 Open Enrollment, 2,781,260 people have selected plans for next year. That number is up from 2017 Open Enrollment, when 2,137,717 people selected plans in the first four weeks of the enrollment period.


Memorandum: Preparation for Launch of New Long-Term Care Survey Process (LTCSP)
On November 24, CMS published a Memorandum to state survey agency directors regarding the launch of the new LTCSP on November 28, 2017. In preparation for the new LTCSP, Appendix P of the State Operations Manual will no longer be accessible, as the LTCSP procedure guide will replace Appendix P as the new procedural and technical guide for conducting surveys. The memorandum also includes a link to resources necessary for surveyors to conduct LTC surveys.

Effective date: Immediately. The information should be communicated with all survey and certification staff, their managers, and the state/regional office training coordinators within 10 days of the memorandum.   


Memorandum: Temporary Enforcement Delays for Certain Phase 2 F-Tags and Changes to Nursing Home Compare
On November 24, CMS published a Memorandum to state survey agency directors regarding implementation of new regulations for nursing homes under Phase Two of the three-part phase-in of the new skilled nursing facility and nursing facility Requirements for Participation. The memorandum discusses the following:

  • Temporary moratorium on imposing certain enforcement remedies for specific Phase 2 requirements
  • Frozen health inspection star ratings on the Nursing Home Compare website
  • Availability of survey findings under new long-term care survey process
  • Methodological changes and changes in Nursing Home Compare

Effective date: November 28, 2017. This policy should be immediately communicated to all survey and certification staff, their managers, and the state/regional office training coordinators.


Recovery Audit Program Improvements Document

On November 24, CMS posted a Document listing the Recovery Audit Program improvements and the respective implementation dates in the downloads section of the Program Reports webpage. All program enhancements have been completed with the current Recovery Audit Contractor awards.


Excluding Noncovered Versions When Setting Payment for Two Part B Drugs Would Have Resulted in Lower Drug Costs for Medicare and its Beneficiaries
On November 27, the Office of Inspector General published a Report on a study reviewing the effect of including self-administered drugs that typically would not be covered under Part B when setting payment amounts for certain Part B drugs. The study found that CMS--by including noncovered, self-administered versions of two Part B drugs--caused Medicare and its beneficiaries to pay an extra $366 million from 2014 through 2016.  

OIG recommends CMS seek a legislative change to provide agency flexibility to determine when noncovered versions of a drug should be included in Part B payment calculations. CMS did not concur with the recommendation because it said further analysis on cost, policy, and operational implications should be done before the agency seeks a legislative change.


Market Saturation and Utilization Data Tool

On November 28, CMS published a Fact Sheet regarding the sixth release of the Market Saturation and Utilization Data Tool. This release includes a quarterly update of data to 12 health service areas from the fifth release of the tool and also includes cardiac rehabilitation programs and psychotherapy data.


Rescinded Advisory Opinion 06-04
On November 28, the Office of Inspector General published a Final Notice rescinding Advisory Opinion No. 06-04, dated April 20, 2006, due to the Requestor’s failure to comply with certain factual certifications made to the OIG pursuant to 42 C.F.R. § 1008.38. The original advisory opinion concerned a nonprofit, tax-exempt, charitable corporation’s proposal to provide financially needy Medicare beneficiaries with assistance with premiums and cost-sharing obligations.

However, the OIG determined that the Requestor provided patient-specific data to donors that would enable donors to correlate the amount and frequency of donations with the number of subsidized prescriptions or orders for their products, and the Requestor allowed donors to influence (directly or indirectly) the identification or delineation of the Requestor’s disease categories. As such, the OIG rescinded the advisory opinion retroactive to April 20, 2006. The advisory opinion will be deemed to have been without force and effect at any time.


Elimination of the GT Modifier for Telehealth Services

On November 29, CMS published Medicare Claims Processing Transmittal 3929, which rescinds and replaces Medicare Claims Processing Transmittal 3817, dated July 28, 2017, to add a new business requirement regarding the way telehealth service information should be displayed in the Multi-Carrier System Desktop Tool. The original transmittal eliminated the use of the GT modifier on professional claims for telehealth services. As of the date of publication of Transmittal 3929, all sensitive/controversial language was removed from the change request.

Effective date: January 1, 2018

Implementation date: January 2, 2018


FDA Announces Approval, CMS Proposes Coverage of First Breakthrough-Designated Test to Detect Extensive Number of Cancer Biomarkers

On November 30, CMS issued a Press Release regarding the FDA approval of the FoundationOne CDx (F1CDx) next generation sequencing (NGS)-based in vitro diagnostic (IVD) test to detect genetic mutations across 324 genes. This test would help doctors tailor cancer treatments to the individual patient. On the same date, CMS published a Proposed Decision Memo seeking coverage with evidence development for the test and other similar NGS IVDs for patients with advanced cancer who meet certain requirements.


Semiannual Report to Congress

On November 30, the Office of Inspector General published the fall edition of the Semiannual Report to Congress covering OIG activity from April 2017 through September 2017. A significant portion of the report concerns activity related to Medicare and Medicaid.


Final Rule: Cancellation of Advancing Care Coordination Through Episode Payment and Cardiac Rehabilitation Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement Payment Model

On December 1, CMS published a Final Rule in the Federal Register to cancel the Advancing Care Coordination Through Episode Payment and Cardiac Rehabilitation Incentive Payment Models. The rule also makes changes to the Comprehensive Care for Joint Replacement (CJR) model pertaining to participation in the model; technical refinements and clarifications for certain payment, reconciliation, and quality provisions; and an increase to the pool of eligible clinicians qualifying as affiliated practitioners under the Advanced Alternative Payment Model track.

The final rule also contains an interim final rule with comment period in order to address the need for a policy which would provide some flexibility in determining episode costs for providers located in areas impacted by extreme and uncontrollable circumstances. Comments on the interim final rule must be submitted no later than 5 p.m. EST on January 30, 2018.

On November 30, CMS published a Press Release and a Fact Sheet to accompany the final rule.

Effective date: January 1, 2018


Report: CMS Did Not Adequately Address Discrepancies in the Coding Classification for Kwashiorkor

On December 1, the Office of Inspector General published a Report regarding CMS’ role in incorrect coding for Kwashiorkor. The OIG found that, in 2,145 inpatient claims dating from 2006 through 2014, all but one claim incorrectly included the diagnosis code for Kwashiorkor, which resulted in overpayments in excess of $6 million.

The ICD-CM coding classification had a discrepancy in the tabular list and alphabetic index which directed four other malnutrition diagnoses to code 260 when code 260 should have only been assigned for Kwashiorkor. Although CMS was aware of the discrepancy, it did not take any action to address it, resulting in a potential loss of approximately $102 million from 2006 through 2014.

OIG recommends CMS review provider claims to ensure the diagnosis code for Kwashiorkor is used correctly by providers and formalize procedures for notifying providers how to correctly bill diagnosis codes when there is a discrepancy in the coding classification between the alphabetic index and tabular list. CMS concurs with the OIG recommendation.


Hospice Manual Update Only for Section 30.3

On December 1, CMS published Medicare Claims Processing Transmittal 3930 to provide clarification on the data required on institutional claims pertaining to diagnosis codes and attending provider names and identifiers. The change request also provides input/output record layout for the Hospice pricer.

Effective date: March 1, 2018

Implementation date: March 1, 2018


Fiscal Year 2014 and 2015 Worksheet S-10 Revisions: Further Extension for all Inpatient Prospective Payment System (IPPS) Hospitals

On December 1, CMS published One-Time Notification Transmittal 1981 to extend the deadline for uploading revised or initial Worksheet S-10 submissions to the Health Care Provider Cost Report Information System (HCRIS). All IPPS hospitals should submit amended FY 2014 and FY 2015 cost reports to Medicare Administrative Contractors (MACS) on or before January 2, 2018. The transmittal also provides clarification on deadlines for MACS to issue Notices of Reopening and lists other submission requirements.  

Effective date: January 2, 2018

Implementation date: January 2, 2018