This week in Medicare updates—11/21/18
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
On November 9, CMS published One-Time Notification Transmittal 2202 regarding the maintenance update of ICD-10 conversions and other coding updates specific to NCDs as a result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Effective date: April 1, 2019 - unless otherwise noted in requirements
Implementation date: April 1, 2019 - for SSMs, for local MACs 60 days from issuance of CR
User CR: Fiscal Intermediary Shared System (FISS) - Implementation of the Molecular Diagnostic Services (MolDX)
On November 9, CMS published One-Time Notification Transmittal 2201 regarding the implementation of the MolDX program for Part A MACs. A detail line field must be created in FISS to allow providers to input test IDs during electronic claim submissions.
On November 13, CMS published MLN Matters 10760 to accompany the transmittal.
Effective date: April 1, 2019
Implementation date: April 1, 2019
Revisions to Medicare Claims Processing Manual Reference to Burn MS-DRGs for Transfer Policy
On November 9, CMS published Medicare Claims Processing Transmittal 4166 to remove burn MS-DRGs that are incorrectly listed as not subject to the transfer payment policy.
Effective date: December 11, 2018
Implementation date: December 11, 2018
Enhancing the Verification Process of Common Working File (CWF) Part A Provider Inquiries
On November 9, CMS published One-Time Notification Transmittal 2198 to modify the provider inquiries and establish an NPI and submitter ID verification process similar to those established in the HIPAA Eligibility Transaction System.
On November 13, CMS published MLN Matters 10983 to accompany the transmittal.
Effective date: April 1, 2019 - NPI verification; July 1, 2019 - Submitter ID verification
Implementation date: April 1, 2019 - Implement NPI verification BRs 1 through 4; July 1, 2019 - Implement submitter ID verification BRs 5 through 8
Ordering External Breast Prostheses and Supplies for Patients
On November 13, CMS published a Fact Sheet regarding Medicare coverage and documentation requirements for physicians who order external breast prostheses and supplies for their patients. The fact sheet includes a table listing required elements for detailed written orders, guidance on what constitutes medical necessity for these supplies, and links to additional Medicare resources on the topic.
Updated Civil Monetary Penalties and Affirmative Exclusions
On November 13, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions agreements, including:
- On October 30, Cal-Devon Urgent Care, Inc., of Chicago, Illinois, reached a $224,151.48 settlement with the OIG to resolve allegations that it submitted claims for a procedure under HCPCS code 96965 that should not have been separately billed and was not medically necessary.
- On October 30, Angela Smith, M.D., and Willow Wellness Center, P.A., of Tyler, Texas, reached a $629,264.14 settlement with the OIG to resolve allegations of submitting claims for HCPCS code 80502 when no consultation request had been made, no written narrative report by a consultant pathologist was produced, and no exercise of medical judgment by a consultant pathologist was required.
The list also includes two settlements from facilities who allegedly employed individuals they knew or should have known were excluded from participation in federal healthcare programs. Those facilities include:
- Resource Center for Independent Living, Inc., of Osage City, Kansas
- Wayside Farm, Inc., of Peninsula, Ohio
Payments Made By Novitas Solutions, Inc., to Hospitals for Certain Advanced Radiation Therapy Services Did Not Fully Comply With Medicare Requirements
On November 14, the OIG published a Review of whether Novitas payments on selected at-risk claims for outpatient intensity-modulated radiation therapy (IMRT) services complied with Medicare requirements. The OIG found that Novitas incorrectly paid hospitals for IMRT services for 98 of the 100 beneficiaries associated with the review. The OIG said Novitas’ overpayments resulted from the Novitas claim system not properly preventing payments to hospitals for all incorrectly billed IMRT services and hospitals misinterpreting or being unfamiliar with Medicare guidance when billing for certain IMRT services. The OIG estimated that hospitals in jurisdictions H and L received at least $7.2 million in overpayments from Novitas during the audit period.
The OIG made three recommendations regarding recovering the overpayments identified in the report and made two procedural recommendations to implement payment edits and education on proper billing for IMRT services. Novitas partially agreed with the recommendations but said it would be unable to demand the estimated overpayments associated with certain error types because specific extrapolated amounts for each provider were not identified.
Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2019
On November 14, CMS published Medicare Benefit Policy Transmittal 250, which rescinds and replaces Transmittal 247, dated October 25, 2018, to update the adjusted average outlier service Medicare allowable payment (MAP) amounts. The original transmittal was issued to implement the CY 2019 rate updates for the ESRD PPS and to implement the payment for renal dialysis services furnished to beneficiaries with AKI in ESRD facilities.
On November 15, CMS published MLN Matters 11021 to accompany the transmittal.
Effective date: January 1, 2019
Implementation date: January 7, 2019
CMS Strengthens Federal Support to California Residents Affected By Wildfires
On November 14, CMS published a Press Release on actions it is taking to support California residents displaced and recovering from wildfires. These actions include temporary waivers for certain Medicare requirements, special enrollment opportunities to allow for immediate access to healthcare, and steps to ensure dialysis patients can obtain services. For more information on CMS activities related to wildfire relief, visit CMS’ emergency website.
On November 15, CMS published Special Edition MLN Matters 18025 to provide information on the special waivers and services available to assist in wildfire relief efforts in California.
New Waived Tests
On November 15, CMS published Medicare Claims Processing Transmittal 4169, which rescinds and replaces Transmittal 4137, dated September 21, 2018, to revise bullet 12 in the background section associated with CPT code 81003QW. The original transmittal was issued to inform contractors of the new CLIA waived tests. There are 16 newly added waived complexity tests listed in the transmittal. CPT codes for these tests should include modifier -QW to identify the waived test.
On November 16, CMS published a revised MLN Matters 10958 to accompany the transmittal.
Effective date: January 1, 2019
Implementation date: January 7, 2019
CMS Web Interface Data Dictionary for Excel Template
On November 15, CMS published a Data Dictionary for the CMS Web Interface Excel Template. The document explains and describes elements from the Excel template to prepare providers to use that template to report data. It also lists data constraints, formats, and notes for each data element.
Updated OIG Work Plan
On November 15, the OIG updated its Work Plan with the following new items:
· Assessing Inpatient Hospital Billing for Medicare Beneficiaries
· Involuntary Transfer and Discharge in Nursing Homes
· Protecting Medicare Hospice Beneficiaries From Harm
· Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries - 10-Year Update
Comment Request: Home Health (HH) National Provider Survey
On November 15, CMS published a Comment Request in the Federal Register regarding an information collection titled, “Home Health (HH) National Provider Survey.” Comments on the information collection are due by January 14, 2019.
Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year 2019
On November 15, CMS published Medicare Claims Processing Transmittal 4148 to implement multiple provisions of the 2019 HH PPS rate update.
On November 16, CMS published MLN Matters 10992 to accompany the transmittal.
Effective date: January 1, 2019
Implementation date: January 7, 2019
CMS Achieved Improper Payment Rate Reductions in Medicare Fee-For-Service (FFS), Medicare Part C, Medicare Part D, Medicaid, and Children’s Health Insurance Program
On November 15, CMS published a Press Release to announce it achieved a program-wide reduction in improper payment rates, marking the first time in improper payment reporting history that CMS achieved reductions in all five programs’ improper payment rates. Most notably, the 2018 FFS improper payment rate dropped to 8.12%, down from 9.51% in 2017.
Advisory Opinion 18-14
On November 16, the OIG published an Advisory Opinion regarding a drug company’s proposal to provide a drug used to treat an epileptic syndrome to hospitals for free if used exclusively to treat inpatients with the specific syndrome. The Requestor stated that hospitals are generally reluctant to stock the drug in part because government programs and other insurers do not provide sufficient reimbursement to cover the cost of the drug, which is not separately reimbursable when administered in the inpatient setting. The Requestor inquired as to whether the agreement would constitute grounds for the impositions of sanctions under the anti-kickback statute.
The OIG determined that this arrangement would potentially generate prohibited remuneration under the anti-kickback statute and the OIG could potentially impose administrative sanctions on the company. This decision was made in part due to publicly available information outside of what the Requestor presented to the OIG. This included information about the price of the drug, which the company increased from $1,650 in 2001 to $23,000 in 2007, an almost 1300% increase in just six years. The current list price of the drug is $38,892, and net sales for the drug were 10 times higher in 2017 than they were in 2008 despite the fact that the number of patients diagnosed with the syndrome remains similar from year to year.
Top Management and Performance Challenges Facing HHS
On November 16, the OIG published a List of the 10 top management and performance challenges facing the Department of Health and Human Services in 2018. The list includes but is not limited to:
- Preventing and treating opioid misuse
- Ensuring program integrity in Medicare Fee-for-Service and Effective Administration of Medicare
- Ensuring value and integrity in managed care and other innovative healthcare payment and service delivery models
Continued Approval of the Community Health Accreditation Partner’s Hospice Accreditation Program
On November 16, CMS published a Final Notice in the Federal Register to announce its decision to approve the Community Health Accreditation Partner (CHAP) for continued recognition as a national accrediting organization for hospices.
Effective date: The approval is effective November 20, 2018 through November 20, 2024.
IVIG Demonstration: Payment Update for 2019
On November 16, CMS published Demonstrations Transmittal 211 regarding the 2019 payment rate for Q2052 (services, supplies, and accessories used in the home under the Medicare IVIG demonstration). The payment rate for January 1, 2019 - December 31, 2019 will be $366.25.
Effective date: January 1, 2019 - payment rate update for 2019
Implementation date: January 7, 2019 - update with January 2019 quarterly release
Revisions to State Operations Manual (SOM) Chapter 7
On November 16, CMS published State Operations Provider Certification Transmittal 185 regarding revisions to SOM Chapter 7 to reflect the guidance related to the Immediate Imposition of Federal Remedies. Sections of Chapter 7 are being revised to include previous language that has been renumbered, moved, and/or consolidated.
Effective date: November 16, 2018
Implementation date: November 16, 2018