This week in Medicare updates–01/06/2016
January 2016 update of the hospital OPPS
On December 18, 2015, CMS released a recurring update notification describing changes to and billing instructions for various payment policies implemented in the January 2016 OPPS update. The January 2016 Integrated Outpatient Code Editor (I/OCE) and OPPS Pricer will reflect the HCPCS, APC, HCPCS Modifier, and Revenue Code additions, changes, and deletions identified in this change request. This recurring update notification applies to Chapter 4, Medicare Claims Processing Manual, section 50.8.
Effective date: January 1, 2016
Implementation date: January 4, 2016
View Transmittal R3425CP.
View MLN Matters article MM9486.
April 2016 quarterly update for the DME, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP)
On December 18, 2015, CMS released a recurring update notification updating the DME CBP files, which is done on a quarterly basis in order to implement necessary changes to the HCPCS, ZIP code, Single payment amount, and Supplier files. These requirements provide specific instruction for implementing the DMEPOS CBP files. The recurring update notification applies to Chapter 23, Medicare Claims Processing Manual, section 100.
Effective date: April 1, 2016
Implementation date: April 4, 2016
View Transmittal R3424CP.
View MLN Matters article MM9477.
Summary of policies in the calendar year (CY) 2016 Medicare Physician Fee Schedule (MPFS) final rule and Telehealth Originating Site Facility Fee payment amount
On December 18, 2015, CMS released a change request providing a summary of the policies in the CY 2016 MPFS final rule and announces the Telehealth Originating Site Facility Fee payment amount. The attached recurring update notification applies to Publication 100-04, Medicare Claims Processing Manual, Chapter 12, section 190.6.
Effective date: January 1, 2016
Implementation date: January 4, 2016
View Transmittal R3423CP.
View MLN Matters article MM9476.
FY 2017 and after payments to hospice agencies that do not submit required quality data
On December 18, 2015, CMS released a change request revising Pub. 100-22, Medicare Quality Reporting Incentive Programs, Chapter 3, section 40, to reflect changes to the payment reduction reconsideration process. It also includes general clarifications to the section. This change request rescinds and fully replaces CR9091.
Effective date: January 1, 2016
Implementation date: April 1, 2016
View Transmittal R52QRI.
View MLN Matters article MM9460.
Revision to new influenza virus vaccine code
On December 22, 2015, CMS rescinded Transmittal 3403 and replaced it with Transmittal 3429. The new influenza virus vaccine code 90630 was effective August 1, 2015, and remains in effect. The coinsurance and deductible do not apply for professional claims with the influenza virus vaccine code 90630 and MACs have been instructed to process and pay for professional claims with dates of service on or after August 1, 2015. All other information remains the same.
Effective date: August 1, 2015
Implementation date: December 11, 2015, for requirement 9357.8; April 4, 2016, for all other requirements
View Transmittal R3429CP.
View MLN Matters article MM9357.
Advance Care Planning as an optional element of an Annual Wellness Visit
On December 22, 2015, CMS made public Transmittal 216 and Transmittal 3428 to reflect the finalization of the policy changes published in the CY 2016 Physician Fee Schedule final rule related to Advance Care Planning provided with the Annual Wellness Visit.
Effective date: January 1, 2016
Implementation date: January 4, 2016
View Transmittal R216BP.
View Transmittal R3428CP.
View MLN Matters article MM9271.
Submission for OMB Review; Comment Request
On December 28, 2015, CMS posted a notice in the Federal Register stating it is accepting comments on: CMS–10079, Hospital Wage Index Occupational Mix Survey and Supporting Regulations in 42 CFR, Section 412.64; CMS–10564, Home Health Face-to-Face Encounter Clinical Templates. Comments are due January 27.
View the notice in the Federal Register.
Leave a comment.
January 2016 update of the ASC payment system
On December 29, 2015, CMS released a recurring update notification describing changes to billing instructions for various payment policies implemented in the January 2016 ASC payment system update. As appropriate, this notification also includes a manual instruction and updates to the HCPCS.
Effective date: January 1, 2016
Implementation date: January 4, 2016
View Transmittal R3430CP.
Notice of modification of OIG Advisory Opinions No. 11-05, 07-06, 07-11 and 06-04
In December 2015, the OIG posted notices of modification of Supplemental Special Advisory Bulletins regarding Independent Charity Patient Assistance Programs. The supplemental bulletin provides additional guidance on patient assistance programs operated by independent charities to address certain risks about these programs that have come to the OIG’s attention in recent years. The OIG sent the Supplemental Bulletin, together with targeted letters, to all independent charities that have received favorable advisory opinions from the OIG to request certain clarifications and modifications to those opinions.
View modified Opinion 11-05.
View modified Opinion 07-06.
View modified Advisory Opinion 07-11.
View modified Opinion 06-04.
OIG Advisory Opinion No. 15-15
On December 29, 2015, the OIG posted Advisory Opinion 15-15 regarding a proposal for a hospital to bill a radiology group for transcription of the radiology group’s reports for individuals who are not hospital patients, but rather patients of a third-party clinic that provides the technical component of the radiology exams.
View the opinion.
Prior authorization process for certain DMEPOS
On December 30, 2015, CMS posted a final rule in the Federal Register establishing a prior authorization program for certain DMEPOS items that are frequently subject to unnecessary utilization. This rule defines unnecessary utilization and creates a new requirement that claims for certain DMEPOS items must have an associated provisional affirmed prior authorization decision as a condition of payment. This rule also adds the review contractor’s decision regarding prior authorization of coverage of DMEPOS items to the list of actions that are not initial determinations and therefore not appealable. These regulations are effective February 29.
View the final rule in the Federal Register.
View the fact sheet.
Correction to ESRD PPS, and Quality Incentive Program
On December 31, 2015, CMS posted a notice in the Federal Register correcting technical and typographical errors that appeared in the final rule published in the Federal Register on November 6, 2015, entitled ‘‘Medicare Program; End-Stage Renal Disease Prospective Payment System, and Quality Incentive Program.’’ This correction is effective on December 31, 2015.
View the notice in the Federal Register.
Certification frequency and requirements for the reporting of quality measures under CMS programs
On December 31, 2015, CMS posted a request for information in the Federal Register seeking public comment regarding several items related to the certification of health information technology (IT), including EHR products used for reporting to certain CMS quality reporting programs such as, but not limited to, the Hospital Inpatient Quality Reporting Program and the Physician Quality Reporting System. In addition, CMS is requesting feedback on how often to require recertification, the number of clinical quality measures a certified Health IT Module should be required to certify to, and testing of certified Health IT Module(s). Comments are due February 1.
View the notice in the Federal Register.
Leave a comment.
Reviewing short stay hospital claims for patient status for admissions on or after January 1
On December 31, 2015, CMS posted a guidance on its Inpatient Hospital Reviews page regarding the change in patient status review resulting from recently revised regulatory rules.
View the guidance.