This week in Medicare updates
Automation of the request for reopening claims process
On December 19, CMS released a change request implementing NUBC approved bill type and condition codes for a request for reopening. Transmittal 3060, dated September 3, 2014, is being rescinded and replaced by Transmittal 3154 201x, to add "a condition code W2, and a condition code D0, D1, D2, D4, D9, or E0" to Business Requirement 8185.2, to clarify Business Requirement 8185.5 creates a system report that is used by A/MACs to complete CMS reporting, to add "for each of the adjustment reason codes R1-R3 for a total of 3 reason codes" to Business Requirement 8185.8 and to add new Business Requirements 8185.3.1, 8185.3.2, 8185.12 8185.12.1, 8185.13, and 8185.14 that were missed during analysis. All other information remains the same.
Effective date: October 1, 2014-Analysis and Design (CWF, FISS and FISS USERS); Claims received on or after April 1, 2015-(CWF, FISS and FISS USERS)
Implementation date: October 6, 2014-Analysis and Design (CWF, FISS and FISS USERS); January 5, 2015–Coding and April 6, 2015; July 6, 2015–Full Implementation (CWF, FISS and FISS USERS)
View Transmittal R3154CP.
January 2015 Integrated Outpatient Code Editor (I/OCE) specifications version 16.0
On December 19, CMS released a change request providing the Integrated OCE instructions and specifications for the Integrated OCE to be utilized under the OPPS and Non-OPPS for hospital outpatient departments, community mental health centers, all non-OPPS providers, and for limited services when provided in a home health agency not under the Home Health PPS or to a hospice patient for the treatment of a non-terminal illness. The attached recurring update notification applies to 100-04, Medicare Claims Processing Manual, Chapter 4, section 40.1.
Effective date: January 1, 2015
Implementation date: January 5, 2015
View Transmittal R3153CP.
Calendar Year (CY) 2015 annual update for clinical laboratory fee schedule and laboratory services subject to reasonable charge payment
On December 19, CMS released a recurring update notification provides instructions for the CY 2015 clinical laboratory fee schedule, mapping for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment. This recurring update notification applies to Medicare Claims Processing Manual, Chapter 16, section 20.
Effective date: January 1, 2015
Implementation date: January 5, 2015
View Transmittal R3152CP.
View MLN Matters article MM9028.
CMP Analytic Tool and Submission of CMP Tool Cases
On December 19, CMS issued the following guidance to notify states CMS Regional Offices (ROs) are required to continue to use the CMP Analytic Tool and guidance in establishing CMPs, but are no longer required to submit CMP Analytic Tool cases to the CMS Central Office. On March 22, 2013, CMS issued guidance stating all ROs were required to use this guidance and CMP Analytic Tool as a guide to choose the appropriate type of CMP to be imposed and to calculate the baseline CMP amount, for all new enforcement cases when the RO determines that a CMP is an appropriate enforcement remedy. CMS issued the CMP Analytic Tool and guidance to promote more consistent application of enforcement remedies for skilled nursing facilities, nursing facilities, and dually-certified facilities (collectively referred to as “nursing homes” or “facility(ies)”).
View the survey and certification letter.
Release of CLIA Brochure #12, “Considerations When Deciding to Develop an IQCP” and Brochure #13, “What is an IQCP?”
On December 19, CMS posted a memorandum announcing the release of CLIA Brochure #12, Considerations When Deciding to Develop an IQCP and Brochure #13, What is an IQCP? These brochures will available on the CLIA website.
View the survey and certification letter.
Guidance related to new state operating manual and Appendix N for psychiatric residential treatment facilities (PRTF)
On December 19, CMS posted a new State Operating Manual and interpretive guidelines in the following State Operations Manual Appendices to reflect recent amendments to the applicable CoPs: Appendix N–PRTF. The revised regulations and their associated guidance were effective July 11, 2014, with the exception of the RHC change concerning the requirement to employ at least one Nurse Practitioner or Physician’s Assistant; this latter change was effective July 1, 2014.
View the survey and certification letter.
January 2015 update of the hospital OPPS
On December 22, CMS released a recurring update notification which describes changes to and billing instructions for various payment policies implemented in the January 2015 OPPS update. The January 2015 Integrated Outpatient Code Editor (I/OCE) and OPPS Pricer will reflect the Healthcare Common Procedure Coding System (HCPCS), Ambulatory Payment Classification (APC), HCPCS Modifier, and Revenue Code additions, changes, and deletions identified in this change request. This Recurring Update Notification applies to Medicare Claims Processing Manual, Chapter 4, section 200.9. The January 2015 revisions to I/OCE data files, instructions, and specifications are provided in the forthcoming January 2015 I/OCE change request. Transmittal 3150, dated December 12, 2014, is being rescinded and replaced by Transmittal 3156 to correct some values in Attachment A, table 8. All other information remains the same.
Effective date: January 1, 2015
Implementation date: January 5, 2015
View Transmittal R3156CP.
View MLN Matters article MM9014.
FFS ED Notice updates
On December 22, CMS posted updated information regarding Notices and Explanation of Medicare non-coverage.
View the documents.
Medicare paid $22 million in 2012 for potentially inappropriate ophthalmology claims
On December 23, OIG posted a report detailing a study of Medicare payments made in 2012 to screen for, diagnose, evaluate, or treat cataracts, wet age related macular degeneration (wet AMD), and glaucoma. Medicare uses a combination of national and local coverage requirements to determine whether it will cover services for these conditions. This study details investigations into some ophthalmology services for these conditions found to be vulnerable to fraud, waste, and/or abuse.
View the report.
January 2015 update of the ASC payment system
On December 24, CMS released a recurring update notification which describes changes to billing instructions for various payment policies implemented in the January 2015 ASC payment system update. This recurring update notification applies to Medicare Claims Processing Manual, Chapter 14, section 10. As appropriate, this notification also includes updates to the HCPCS.
Effective date: January 1, 2015
Implementation date: January 5, 2015
View Transmittal R3158CP.
Summary of policies in the CY 2015 Medicare Physician Fee Schedule (MPFS) final rule and Telehealth Originating Site Facility Fee payment amount
On December 24, CMS released a change request provides a summary of the policies in the CY 2015 MPFS final rule and announces the Telehealth Originating Site Facility Fee payment amount. The attached recurring update notification applies to Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 190.6 and Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 270.5.
Effective date: January 1, 2015
Implementation date: January 5, 2015
View Transmittal R3157CP.
Electronic Correspondence Referral System (ECRS) notification regarding Defense of Marriage Act (DOMA) and ICD-10 changes
On December 24, CMS released a transmittal detailing the definition of spouse will change under the MSP working aged provisions. Under the revised definition, a spouse may now include an individual of the same sex. Therefore, CMS has modified the ECRS User Guide to reflect this change. Through the issuance of a final rule on July 31, 2014, the U. S. Department of Health and Human Services formally changed the implementation date for the ICD, Clinical Modifications, version 10, from October 1, 2014, to October 1, 2015. Accordingly, CMS has modified the ECRS User Guide to reflect this change in implementation date for use of ICD-10 codes. Transmittal 105, dated October 10, 2014, is being rescinded and replaced by Transmittal 109 to correct the definition of Reason code 07 in Appendix E and Table E-1. All other information remains the same.
Effective date: October 1, 2014
Implementation date: January 1, 2015
View Transmittal R109MSP.