This week in Medicare updates – 12/27/2017
Clinical Laboratory Improvement Amendments of 1988 (CLIA) Proficiency Testing (PT) Referral Categories
On December 15, CMS published a Memorandum to state survey agency directors explaining the three categories of sanctions for PT referrals included in the final regulations for implementing the Taking Essential Steps for Testing Act (TEST) of 2012. The three categories are based on the severity and extent of the PT referral violation.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state/regional office training coordinators within 30 days of the memorandum.
Medicare Fee-for-Service Response to the 2017 Southern California Wildfires
On December 18, CMS published Special Edition MLN Matters 17037 regarding CMS actions to provide relief from and assistance for those affected by the Southern California wildfires. The MLN Matters article also provides information on Section 1135 and Section 1812(f) waivers issued in response to the wildfires.
Effective date: N/A
Implementation date: N/A
Updated Civil Monetary Penalties and Affirmative Exclusions
On December 18, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusion agreements reached in December, including:
- Dr. Sherry Ma of St. Louis, Missouri, agreed on December 4, 2017 to be excluded from participation in all federal healthcare programs for a period of three years for violating the Civil Monetary Penalties law. The OIG alleged Dr. Ma received medications at no charge that were supposed to be used for specific patients with private insurance. Dr. Ma kept the remaining medications not used for those patients for more than 24 hours and used them on Medicare patients, but Dr. Ma submitted claims for payment to Medicare as if she had purchased the spare vials, according to the OIG.
- Dr. Josette Maria and Maria Medical Center (collectively, “MMC”) of Dunn and Spring Lake, North Carolina, reached a $60,000 settlement with the OIG on December 4, 2017, to resolve allegations of improperly billing for “incident to” services, routinely billing for services provided by unlicensed individuals, and receiving remuneration from laboratory companies in the form of “process and handling” payments in exchange for referring patients for laboratory testing services.
- Addiction Medical Care of Norwalk, Practice Management Associates Norwalk, LLC, Addiction Medical Care of Columbus, and Practice Management Associates, LLC (collectively, “AMC”), in Norwalk and Columbus, Ohio, reached a $79,880.50 settlement with the OIG on December 5, 2017, to resolve allegations of receiving improper remuneration in the form of point of care test cups which resulted in prohibited referrals.
- Dyersburg Hospital Company, LLC d/b/a Dyersburg Regional Medical Center (DRMC), of Dyersburg, Tennessee, reached a $45,000 settlement with the OIG on December 6, 2017, to resolve patient dumping allegations in a case which resulted in the patient’s death.
- Cambridge Health Alliance (Cambridge), of Cambridge, Massachusetts, reached a $90,000 settlement with the OIG on December 12, 2017, to resolve patient dumping allegations in a case which resulted in the patient’s death.
Instructions for Retrieving the 2018 Pricing and HCPCS Data Files through CMS' Mainframe Telecommunications Systems
On December 19, CMS published Medicare Claims Processing Transmittal 3935, which rescinds and replaces Transmittal 3865, dated September 22, 2017, to correct the file name in one of the business requirements. The original transmittal regards the annual update to the various pricing files used by Medicare Administrative Contractors (MAC) to adjudicate Part B fee schedule paid claims.
Effective date: January 1, 2018
Implementation date: January 2, 2018
2018 Medicare Electronic Health Record (EHR) Incentive Program Payment Adjustment Fact Sheet for Eligible Clinicians
On December 19, CMS published a Fact Sheet regarding the 2018 EHR Incentive Program. The fact sheet provides an overview of EHR incentive payments for eligible professionals, the 2018 EHR eligible professional payment adjustment, and the 2018 EHR exceptions process for clinicians.
Updated Corporate Integrity Agreement Documents
On December 20, the OIG published information on a new Corporate Integrity Agreement with United Therapeutics Corporation of Washington, DC.
Tracking Sheet Revision: National Coverage Analysis (NCA) for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer
On December 20, CMS issued a revised NCA Tracking Sheet for the NGS for Medicare Beneficiaries with Advanced Cancer following the FDA Approval Order of the Foundation Medicine Inc. FoundationOne CDxTM on December 18. CMS extended the comment period for the related proposed decision memo until Wednesday, January 17, 2018.
CMS updates website to compare hospital quality
On December 21, CMS issued a Press Release regarding updated data on the Hospital Compare website and on data.medicare.gov. The agency updated Hospital Compare data on quality measures and overall hospital star ratings. CMS will also post supporting documents related to Star Ratings on the QualityNet website.
Lincare Pharmacy Services Inc. Generally Complied with Medicare Requirements when Billing for Inhalation Drugs
On December 21, the OIG published a Report on a review of Lincare Pharmacy Services Inc., to examine whether Lincare complied with Medicare requirements when billing for inhalation drugs. The OIG found that 97 of the 100 reviewed claim lines for inhalation drugs complied with Medicare requirements. The remaining three claims did not contain sufficient documentation in the medical record to support medical necessity requirements for inhalation drugs.
The OIG recommends Lincare ensure medical necessity is adequately supported in the medical record before billing. Lincare concurred with the OIG recommendation.
Updated Editing of Always Therapy Services - MCS
On December 21, CMS published Medicare Claims Processing Manual Transmittal 3936, which rescinds and replaces Transmittal 3863, dated September 15, 2017, to remove HCPCS code 97532 from the list of therapy codes in the attachment. The original transmittal implemented revised editing of Part B “Always Therapy” services to require the appropriate modifier for the service to be accurately applied to the therapy cap.
Effective date: January 1, 2018
Implementation date: January 2, 2018
Correction to Prevent Payment on Inpatient Information-Only Claims for Beneficiaries Enrolled in Medicare Advantage
On December 22, CMS published Medicare Claims Processing Transmittal 3943, which rescinds and replaces Transmittal 3898, dated October 27, 2017, to change the discharge date to admit/from date in three business requirements, remove an edit code in one business requirement, and change new report to existing report in one business requirement. The original transmittal instructed MACs to enable the Common Working File (CWF) to set edit 5233 on inpatient information-only claims billed with condition codes 04 and 30 for Investigational Device Exemption Studies and Clinical Studies Approved Under Coverage with Evidence Development. This edit would then allow the Fiscal Intermediary Standard System (FISS) to zero out payment.
Effective date: April 1, 2015
Implementation date: April 2, 2018
January 2018 Update of the Ambulatory Surgical Center (ASC) Payment System
On December 22, CMS published Medicare Claims Processing Transmittal 3939 regarding the January 2018 ASC payment system recurring update notification, which describes changes to and billing instructions for various payment policies implemented in the update. The notification also applies to and updates Chapter 14 of the Internet-Only Manual and includes updates to applicable HCPCS codes.
Effective date: January 1, 2018
Implementation date: January 2, 2018
Summary of Policies in the Calendar Year (CY) 2018 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, and CT Modifier Reduction List
On December 22, CMS published Medicare Claims Processing Transmittal 3938, which provides a summary of policies in the 2018 MPFS final rule and announces the Telehealth Originating Site Facility Fee payment amount. The recurring update notification applies to the Medicare Claims Processing Manual Chapter 12, Sections 190.5 and 240.
Effective date: January 1, 2018
Implementation date: January 2, 2018
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2018
On December 22, CMS published Medicare Claims Processing Transmittal 3937 to announce changes included in the April 2018 quarterly release of the edit module for clinical diagnostic laboratory services.
Effective date: October 1, 2017
Implementation date: April 2, 2018
Clinical Laboratory Fee Schedule - Medicare Travel Allowance Fees for Collection of Specimens
On December 22, CMS published Medicare Claims Processing Transmittal 3942 to revise the payment of travel allowances for CY 2018 when billed on a per mileage basis using HCPCS code P9603 and when billed on a flat rate basis when using HCPCS code P9604.
Effective date: January 1, 2018
Implementation date: January 22, 2018
January 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS)
On December 22, CMS published Medicare Claims Processing Transmittal 3941 regarding changes to and billing instructions for various payment policies implemented in the January 2018 OPPS update.
Effective date: January 1, 2018
Implementation date: January 2, 2018
January 2018 Integrated Outpatient Code Editor (I/OCE) Specifications Version 19.0
On December 22, CMS published Medicare Claims Processing Transmittal 3940 to provide the instructions and specifications for the I/OCE 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 Prospective Payment System or to a hospice patient for the treatment of a non-terminal illness.
Effective date: January 1, 2018
Implementation date: January 2, 2018