This week in Medicare update-12/02/2015
Revisions to State Operations Manual (SOM), Appendix A -Survey Protocol, Regulations and Interpretive Guidelines for Hospitals
On November 20, CMS released a transmittal clarifying its interpretive guidance in Appendix A for existing regulations in 42 CFR Part 4 82, concerning preparation and administration of drugs as well as pharmacy requirements and accepted standards of practice for drug compounding.
Effective date: November 20, 2015
Implementation date: November 20, 2015
View Transmittal R151SOMA.
Claim Status Category and Claim Status Codes update
On November 20, CMS released change request to update as needed the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transactions.
Effective date: April 1, 2016
Implementation date: April 4, 2016
View Transmittal R3413CP.
View MLN Matters article MM9427.
Implement Operating Rules-Phase III ERA EFT: CORE 360 Uniform Use of Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) Rule-update from CAQH CORE
On November 20, CMS released change request instructing the contractors and Shared System Maintainers to update systems based on the CORE 360 Uniform Use of CARC and RARC Rule publication. These system updates are based on the CORE Code Combination List to be published on or about February 1, 2016. This recurring update applies to the entire manual.
Effective date: April 1, 2016
Implementation date: April 4, 2016
View Transmittal R3411CP.
View MLN Matters article MM9350.
Remittance Advice Remark and CARC and Medicare Remit Easy Print (MREP) and PC Print update
On November 25, CMS released a change request to update the CARC and RARC lists and also instructs ViPS Medicare System and Fiscal Intermediary Shared System to update MREP and PC Print.
Effective date: April 1, 2016
Implementation date: April 4, 2016
View Transmittal R3418CP.
Quarterly update to the CCI edits, Version 22.1
On November 20, CMS released the normal update to the CCI procedure to procedure edits. The attached recurring update notification applies to Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, section 20.9. This update is effective April 1, 2016.
Effective date: April 1, 2016
Implementation date: April 4, 2016
View Transmittal R3408CP.
View MLN Matters article MM9377.
Instructions for downloading the Medicare ZIP Code file for April 2016
On November 20, CMS released a change request to provide instruction for updating the two Medicare ZIP Code files (ZIP5 and ZIP9) for the April 2016 quarter. The attached recurring update notification applies to Medicare Claims Processing Manual, Chapter 15, section 20.1.5 (B).
Effective date: April 1, 2016
Implementation date: April 4, 2016
View Transmittal R3409CP.
Payment for grandfathered tribal federally qualified health centers that were provider-based clinics on or before April 7, 2000
On November 23, CMS rescinded Transmittal 3313, dated August 6, 2015, and replaced it with Transmittal 3415 to add a provider education requirement and updated references to the Physician Fee Schedule proposed and final rules. This transmittal is no longer sensitive/controversial, and may be posted to the internet. All other information remains the same.
Effective date: January 1, 2016
Implementation date: January 4, 2016
View Transmittal R3415CP.
CY 2016 update for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) Fee Schedule
On November 23, CMS released a recurring update notification providing instructions on the CY 2016 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule. This recurring update notification applies to Chapter 23, section 60 of Pub. 100-04 Medicare Claims Processing Manual.
Effective date: January 1, 2016
Implementation date: January 4, 2016
View Transmittal R3416CP.
View MLN Matters article MM9431.
National Government Services, Inc. (NGS), made Medicare payments for diabetic test strips when beneficiaries had not nearly exhausted previously dispensed supplies
On November 23, the OIG posted a report stating that NGS, the durable medical equipment Medicare administrative contractor for Jurisdiction B, made payments for calendar year 2013 to suppliers that dispensed diabetic test strips when the beneficiaries had not nearly exhausted test strips previously dispensed by different suppliers. On the basis of the sample results, the OIG estimated that $3.2 million of the $4.4 million that NGS paid to suppliers may have been unallowable for Medicare reimbursement.
View the report.
Medicare Compliance Review of Sierra View Medical Center
On November 23, the OIG posted a report stating that Sierra View Medical Center complied with Medicare billing requirements for five of the 30 inpatient and outpatient claims reviewed. However, the medical center did not fully comply with Medicare billing requirements for the remaining 25 claims, resulting in overpayments of approximately $798,000. These overpayments occurred primarily because the medical center did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors.
View the report.
Comprehensive Care for Joint Replacement (CJR) Payment Model for acute care hospitals furnishing lower extremity joint replacement services
On November 24, CMS posted a final rule in the Federal Register implementing a new Medicare Part A and B payment model, called the Comprehensive CJR model, in which acute care hospitals in certain selected geographic areas will receive retrospective bundled payments for episodes of care for lower extremity joint replacement or reattachment of a lower extremity. All related care within 90 days of hospital discharge from the joint replacement procedure will be included in the episode of care. CMS believes this model will further its goals in improving the efficiency and quality of care for Medicare beneficiaries with these common medical procedures. These regulations are effective on January 15, 2016, and applicable on April 1, 2016 when the first model performance period begins.
View the final rule in the Federal Register.
Part B Payments for 340B Purchased Drugs
On November 24, the OIG posted a report stating that Medicare Part B and its beneficiaries paid $3.5 billion for 340B-purchased drugs in 2013. In the aggregate, Part B payment amounts were 58% more than the statutorily based 340B ceiling prices that year, which allowed covered entities to retain approximately $1.3 billion. The OIG states that this report presents an independent analysis to inform the ongoing discussion and to support decision makers’ efforts in striking a balance among the needs of these vital programs.
View the report.
Re-communicated transmittal regarding implementation of adjusted DMEPOS fee schedule amounts using information from the National Competitive Bidding Program
On November 25, CMS re-communicated Transmittal R3350CP. This transmittal was originally posted on September 11, 2015. The transmittal number, date of transmittal, and all other information remain the same. This instruction may now be posted on the internet.
Effective date: January 1, 2016
Implementation date: January 4, 2016
View Transmittal R3350CP.
View the fact sheet.
Correction to transmittal regarding Oncology Care Model Monthly Enhanced Oncology Services payment implementation
On November 25, CMS rescinded Transmittal 127, dated November 5, 2015, and replaced it with Transmittal 129 to correct the HCPCS number and add HCPCS admin and pricing information located in the Business Requirement background section, BR 9341.1.1, BR 9341.1.2 and BR 9341.1.3. All other information remains the same.
Effective date: April 1, 2016
Implementation date: April 4, 2016
View Transmittal R129DEMO.
Therapy cap values for CY 2016
On November 25, CMS released a change request to describe the amounts and the policy for outpatient therapy caps for CY 2016. Information related to this recurring update notification can be found in Publication 100-04, Medicare Claims Processing Manual, Chapter 5, section 10.
Effective date: January 1, 2016
Implementation date: January 4, 2016
View Transmittal R3417CP.
View MLN Matters article MM9448.
Correction to IPPS for acute care hospitals and the long-term care hospital prospective payment system policy changes and FY 2016 rates
On November 27, CMS posted a notice in the Federal Register correcting technical and typographical errors in the correcting document that appeared in the October 5, 2015 Federal Register. This correcting document is effective November 25. This correcting document is applicable to discharges beginning October 1, 2015.
View the notice in the Federal Register.
Proposed Collection; Comment Request
On November 27, CMS posted a notice in the Federal Register relating that it is accepting comments on: CMS–10066, Detailed Notice of Discharge (DND) and Supporting Regulations in 42 CFR 405.1206 and 422.622; and CMS–10596, Reapplication Submission Requirement for Qualified Entities under ACA Section 10332. Comments are due January 26.
View the notice in the Federal Register.
Leave a comment.
Announcement of the Advisory Panel on Hospital Outpatient Payment (HOP Panel) meeting
On November 30, CMS posted a notice in the Federal Register announcing a meeting of the HOP Panel for March 14 and 15, 2016. The purpose of the HOP Panel is to advise the secretary of the HHS and the administrator of the CMS on the clinical integrity of the APC groups and their associated weights and hospital outpatient therapeutic services supervision issues. For information about registration and deadlines regarding this meeting, please see the Federal Register notice.
View the notice in the Federal Register.
Town Hall Meeting on the FY 2017 applications for new medical services and technologies add-on payments
On November 30, CMS posted a notice in the Federal Register announcing a Town Hall meeting to discuss FY 2017 applications for add-on payments for new medical services and technologies under the hospital IPPS. Interested parties are invited to this meeting to present their comments, recommendations, and data regarding whether the FY 2017 new medical services and technologies applications meet the substantial clinical improvement criterion. It will be held on Tuesday, February 16, 2016. For information about registration and deadlines regarding this meeting, please see the Federal Register notice.
View the notice in the Federal Register.
Leave a comment.