This week in Medicare updates - 9/22/2015

September 22, 2015
Medicare Insider

2016 annual update of HCPCS codes for SNF Consolidated Billing (CB) update

On September 11, CMS released a transmittal discussing that changes to HCPCS codes and Medicare Physician Fee Schedule designations will be used to revise CWF edits to allow A/B MACs to make appropriate payments in accordance with policy for SNF CB in Chapter 6, Medicare Claims Processing Manual, Section 110.4.1 for A/B MACs (B) and Chapter 6, Section 20.6 for A/B MACs (A).


Effective date: January 1, 2016

Implementation date: January 4, 2016

View Transmittal R3349CP.

View MLN Matters article MM9340.


HHA survey protocol training item revised

On September 11, CMS posted a survey and certification letter regarding the revision of the HHA survey protocol training which provides training on the use of the HHA Survey Protocols. The protocols provide guidance to assist surveyors in determining when a Condition-level deficiency may be considered. Previous trainings emphasized that the phrase “consider citing the Condition” implied the surveyor “should” cite the Condition. CMS has since revised our training in this area to indicate that surveyors may consider citing the Condition when indicated by the regulation but the phrase should not be taken as a prescriptive element of the guidance over survey or judgment.


View the survey and certification letter.


Claims submission alternatives for providers who have difficulties submitting ICD-10 claims

On September 14, CMS released a special edition MLN Matters article to help physicians, providers, and suppliers find information to avoid claims processing disruptions after implementation of ICD-10 on October 1. It provides information for providers who have difficulties submitting ICD-10 claims due to being unable to complete necessary systems changes or having issues with billing software, vendor(s), or clearinghouse(s).


View special edition MLN Matters article SE1522.


October 2015 update of the hospital OPPS

On September 15, CMS rescinded Transmittal 3333, dated August 21, 2015, and replaced it with Transmittal 3352 to change the status indicator for the HCPCS code Q5101, Injection, Filgrastim (G-CSF), Biosimilar, 1 microgram, from E to K and to assign APC 1822 in the October update of the I/OCE. CMS added section I.B.4.g, and a new business requirement #9298.4 to this recurring update notification, and table 6 to the attachment A. All other information remains the same. The original recurring update notification describes changes to and billing instructions for various payment policies implemented in the October 2015 OPPS update.


Effective date: October 1, 2015

Implementation date: October 5, 2015

View Transmittal R3352CP.


Reopening of comment period for reform of requirements for long-term care facilities

On September 15, CMS posted a notice in the Federal Register reopening the comment period for the July 16, 2015 proposed rule entitled ‘‘Reform of Requirements for Long-Term Care Facilities’’. The comment period for the proposed rule, which ends on September 14, 2015, is reopened for 30 days. The reopened comment period for the proposed rule ends on October 14, 2015.


View the notice in the Federal Register.

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Jefferson Hospital incorrectly billed Medicare inpatient claims with Kwashiorkor

On September 15, the OIG posted a report stating Jefferson Hospital, in Jefferson City, Pennsylvania, did not comply with Medicare requirements for billing Kwashiorkor on any of the 46 claims reviewed. The hospital used diagnosis code 260 for Kwashiorkor but should have used codes for other forms of malnutrition or no malnutrition code at all. For one of the inpatient claims, substituting a more appropriate diagnosis code produced no change in the diagnosis-related group payment amount. However, for the remaining 45 inpatient claims, the errors resulted in overpayments of $185,000. Hospital officials attributed these errors to a misinterpretation of the coding guidelines.


View the report.


Questionable billing for Medicare ophthalmology services

On September 16, the OIG posted a report of a study it completed on questionable billing for Medicare ophthalmology services. It found that most providers did not demonstrate questionable billing on any of our measures in 2012, but 4% of providers billing Medicare for ophthalmology services demonstrated at least one of the OIG’s nine measures of questionable billing.


View the report.


National coverage analysis (NCA) for positron emission tomography to identify bone metastasis of cancer

On September 16, CMS posted a proposed decision memorandum stating that the evidence is sufficient to determine that use of a NaF-18 positron emission tomography scan to identify bone metastasis of cancer is not reasonable and necessary to diagnose or treat an illness or injury or to improve the functioning of a malformed body member and, therefore, is not covered.  


View the proposed decision memorandum.


Approval of request for an exception to the Prohibition on Expansion of Facility Capacity Under the Hospital Ownership and Rural Provider Exceptions to the Physician Self-Referral Prohibition

On September 17, CMS posted a final notice in the Federal Register announcing its decision to approve the request from Doctors Hospital at Renaissance for an exception to the prohibition against expansion of facility capacity. This notice is effective on September 11, 2015.


View the notice in the Federal Register.

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