This week in Medicare updates–11/04/2015
NCD for single chamber and dual chamber permanent cardiac pacemakers
On October 26, CMS rescinded Transmittal 179, dated February 20, 2015, and replaced it with Transmittal 186. The NCD for Cardiac Pacemakers: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (NCD20.8.3) was effective on August 13, 2013, and remains in effect. To address claims processing issues that were brought to the attention of the CMS, it has instructed MACs to implement this NCD at the local level until CMS is able to revise the formal claims processing instructions. All aspects of the NCD policy in Publication 100-03, NCD Manual, section 20.8.3, remain in effect. Additionally, CMS is temporarily removing the corresponding Claims Processing Manual, Chapter 32, section 320, and reference to the manual in requirement 9078-03.1 and 9078-03.2. All other information remains the same. This change request rescinds and fully replaces Change Request 8525.
Effective date: August 13, 2013
Implementation date: July 6, 2015
View Transmittal R186NCD.
View Transmittal R3384CP.
View MLN Matters article MM9078.
Medicare Compliance Review of Boca Raton Regional Hospital, Inc., for 2011 and 2012
On October 26, the OIG posted a report stating that Boca Raton Regional Hospital, Inc., complied with Medicare billing requirements for 161 of the 211 inpatient and outpatient claims reviewed. However, the hospital did not fully comply with Medicare billing requirements for the remaining 50 claims, resulting in overpayments of $514,000 for the audit period. The outpatient claims selected for review did not contain errors. These errors occurred primarily because the hospital did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors. On the basis of the sample results, the OIG estimated that the hospital received at least $2.6 million in overpayments from Medicare.
View the report.
FY 2016 results for the CMS Hospital Value-Based Purchasing (VBP) Program
On October 26, CMS posted a fact sheet to give an overview of the Hospital VBP Program, discussing the results of the program in FY 2016 and detailing the direction of the program in future years.
View the fact sheet.
CMS notifies the public of changes in its education and enforcement strategies
On October 26, CMS updated its Inpatient Hospital Reviews webpage with information regarding changes to the Quality Improvements Organizations, MACs, and Recovery Auditor programs. The changes took effective October 1, 2015.
View the Inpatient Hospital Reviews webpage.
ICD-10-CM diagnosis codes for Bone Mass Measurement
On October 28, CMS released a special edition MLN Matters article stating it will implement Change Request 9252 on January 4, 2016, effective October 1, 2015. This change request establishes the list of covered conditions and corresponding ICD-10-CM diagnosis codes approved for Bone Mass Measurement studies according to the requirements set forth in NCD 150.3. The condition of osteopenia and the ICD-10-CM codes that describe it which are classified to subcategory M85.8- Other specified disorders of bone density and structure were inadvertently omitted which are considered covered indications for bone mass measurement under NCD 150.3 and providers should report these appropriately according to medical documentation. Additional guidance and education as to the updated complete list of covered indications will be forthcoming as CMS continues to review this issue and the systems updates required.
View special edition MLN Matters article SE1525.
Final waivers in connection with the Shared Savings Program
On October 29, CMS posted a final rule in the Federal Register finalizing waivers of the application of the physician self-referral law, the federal anti-kickback statute, and the civil monetary penalties (CMP) law provision relating to beneficiary inducements to specified arrangements involving accountable care organizations (ACO). In light of legislative changes that occurred after publication, this final rule does not finalize waivers of the application of the CMP law provision relating to ‘‘gainsharing’’ arrangements. Section 1899(f) of the Act, as added by the Affordable Care Act, authorizes the Secretary to waive certain fraud and abuse laws as necessary to carry out the provisions of this section of the Act. These regulations are effective October 29, 2015.
View the Shared Savings Plan final rule.
CMS announces payment changes for Medicare HHAs for 2016
On October 29, CMS posted a final rule and accompanying fact sheet announcing changes to the Medicare home health prospective payment system (HH PPS) for calendar year (CY) 2016 that will foster greater efficiency, payment accuracy, and improved quality of care.
View the home health final rule.
View the fact sheet.
CMS updates to policies and payment rates for ESRD facilities for CY 2016 and changes to the ESRD Quality Incentive Program
On October 29, CMS posted a final rule and accompanying fact sheet updating payment policies and rates under the ESRD PPS for renal dialysis services furnished to beneficiaries on or after January 1, 2016.
View the ESDR final rule.
View the fact sheet.
Proposed decision memorandum for stem cell transplantation (multiple myeloma, myelofibrosis, and sickle cell disease)
On October 29, CMS posted a proposed decision memorandum to modify its existing NCD at section 110.8.1 of the Medicare National Coverage Determinations Manual to expand national coverage for allogenic hematopoietic stem cell transplantation (HSCT) for three separate medical conditions: multiple myeloma, myelofibrosis, and sickle cell disease.
View the proposed decision memorandum.
ICD-10 transition moves forward
On October 29, CMS posted a fact sheet stating that, on October 1, 2015, health systems across the country transitioned to ICD-10. CMS writes that it has been carefully monitoring the transition and is pleased to report that claims are processing normally.
View the fact sheet.
Discharge planning proposed rule focuses on patient preferences
On October 29, CMS posted a press release stating it proposed to revise the discharge planning requirements that hospitals, including long-term care hospitals and inpatient rehabilitation facilities, critical access hospitals, and home health agencies, must meet to participate in the Medicare and Medicaid programs. The proposed changes would modernize the discharge planning requirements by bringing them into closer alignment with current practice, helping to improve patient quality of care and outcomes, and reducing avoidable complications, adverse events, and readmissions.
View the press release.
OIG Policy Statement regarding hospitals that discount or waive amounts owed by Medicare beneficiaries for self-administered drugs dispensed in outpatient settings
On October 30, the OIG posted a policy statement assuring hospitals that they will not be subject to OIG administrative sanctions for discounting or waiving amounts Medicare beneficiaries may owe for self-administered drugs (SAD) they receive in outpatient settings when those drugs are not covered by Medicare Part B, subject to the specific conditions. This policy statement is designed to address the question whether various guidance documents issued by CMS, including a program memorandum outlining changes in the OPPS for calendar year 2003, require hospitals to bill and collect (or make good faith efforts to collect) their usual and customary charges for SADs that are not covered by Medicare Part B (Noncovered SADs) to comply with OIG’s fraud and abuse authorities.
View the policy statement.
Hospital OPPS and ASC final rule
On October 30, CMS released a final rule revising the Medicare hospital OPPS and the Medicare ASC payment system for CY 2016 to implement applicable statutory requirements and payment changes. In this final rule with comment period, the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system are described in detail.
View the OPPS final rule.
View the fact sheet on OPPS final rule.
View the fact sheet on the 2-midnight rule.
View the OPPS CY 2016 final rule website.
Revisions to payment policies under the physician fee schedule and other revisions to Part B for CY 2016
On October 30, CMS released a major final rule with comment period addressing changes to the physician fee schedule, and other Medicare Part B payment policies to ensure that the payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute.
View the Medicare physician free schedule final rule.
View the fact sheet.
View the 2016 Physician Quality Reporting System (PQRS) payment adjustment fact sheet.