This week in Medicare updates–05/11/2016

May 11, 2016

Medicare Insider

Revision of the method to calculate the length of stay (LOS) edit for continuous invasive mechanical ventilation for greater than 96 consecutive hours

On April 28, CMS released a change request instructing the Fiscal Intermediary Shared System to use the mechanical ventilation procedure code date in the calculation of consecutive days for the LOS edit to more accurately ensure correct coding of mechanical ventilation greater than 96 consecutive hours.

Effective date: October 1, 2016

Implementation date: October 3, 2016

View Transmittal R504CP.

Additional instructions for implementation of Round 2 Recompete of the DME Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP) and National Mail Order Recompete

On April 28, CMS released a change request to provide instructions for implementing changes to the DMEPOS CBP regarding the clarification of the RB modifier for Medicare payment for the repair of parts furnished in Competitive Bidding Areas and clarification of grandfathering instructions for rentals of accessories and supplies.

Effective date: October 1, 2016

Implementation date: October 3, 2016

View Transmittal R500CP.

View MLN Matters article MM9579.

Updating the Fiscal Intermediary Shared System (FISS) to make payment for drugs and biologicals services for OPPS providers

On April 28, CMS released a change request implementing phase 2 of system changes necessary to the FISS and Integrated Outpatient Code Editor (I/OCE) to make payment for drugs and biologicals to OPPS providers.

Effective date: January 1, 2016

Implementation date: October 3, 2016

View Transmittal R1649OTN.

View MLN Matters article MM9601.

Stem cell transplantation for multiple myeloma, myelofibrosis, sickle cell disease, and myelodysplastic syndromes

On April 29, CMS released a change request stating that, effective for claims with dates of service on and after January 27, contractors shall be aware that the use of allogeneic hematopoietic stem cell transplantation (HSCT) for treatment of multiple myeloma, myelofibrosis, and sickle cell disease is only covered by Medicare if provided in the context of a Medicare-approved clinical study meeting specific criteria under the coverage with evidence development (CED) paradigm. This change request also clarifies the ICD-9 and ICD-10 diagnosis codes for allogeneic HSCT for treatment of myelodysplastic syndromes in the context of a Medicare-approved, prospective clinical study under the CED paradigm. See Pub. 100-03, Internet-Only Manual, Chapter 1, section 110.23, of the NCD Manual, for further information.

Effective date: January 1, 2016

Implementation date: October 3, 2016

View Transmittal R3509CP.

View Transmittal R191NCD.

Oncology Care Model (OCM) Monthly Enhanced Oncology Services (MEOS) payment implementation

On April 29, CMS rescinded Transmittal 139, dated February 11, and replaced it with Transmittal 146 to specify that $160 is the base rate for the MEOS payments in the second paragraphs of the Background and Policy sections; to further specify in the first paragraph of the Policy section that this change request will only address G9678 payments and that program recoupments and performance-based payments will be addressed in a separate change request; to update the start of the performance period from April to July 2016 in the third paragraph of the Policy section; to specify in the fourth paragraph of the Policy section that OCM participating practices may bill other care management services for beneficiaries not attributed to the model; to add sequestration to the list of example penalties and payment adjustments G9678 will be subject to in paragraph 5 of the Policy section; to update the description of G9678 in the Policy section; to extend the dates of service to which G9678 will be excepted to June 30, 2021, in BR 9341.1; and to update the date that the first participate file update will be available in BR 9341.2.3 to on or around May 15. All other information remains the same.

Effective date: April 1, 2016

Implementation date: April 4, 2016

View Transmittal R146DEMO.

JW modifier: Drug amount discarded/not administered to any patient

On April 29, CMS released a change request stating that, effective July 1, claims for discarded drugs or biological amounts not administered to any patient, shall be submitted using the JW modifier. Also, effective July 1, providers must document the discarded drugs or biologicals in the patient's medical record. This change request updates section 40, Discarded Drugs and Biologicals, of Chapter 17 of the Medicare Claims Processing Manual.

Effective date: July 1, 2016

Implementation date: July 5, 2016

View Transmittal R3508CP.

View MLN Matters article MM9603.

Changes to the inpatient Provider Specific File (PSF) for low-volume hospital payment adjustment factor and new IPPS Pricer output field for islet isolation add-on payment

On April 29, CMS released a change request that adds the low-volume hospital payment adjustment factor to the PSF and adds an output field for the islet isolation cell transplantation add-on payment.

Effective date: October 1, 2016

Implementation date: October 3, 2016

View Transmittal R3511CP.

Updates to Pub. 100-04, Medicare Claims Processing Manual, Chapters 1 and 16 to correct remittance advice messages

On April 29, CMS released a change request revising Chapters 1 and 16 of the Medicare Claims Processing Manual to ensure that all remittance advice coding is consistent with nationally standard operating rules. It also provides a format for consistently showing remittance advice coding throughout this manual.

Effective date: October 1, 2016

Implementation date: October 3, 2016

View Transmittal R3510CP.

View MLN Matters article MM9578.

System changes to implement section of the Consolidated Appropriations Act, 2016, temporary exception for certain wound care discharges from certain long-term care hospitals (LTCH)

On April 29, CMS released change request implementing a temporary exception for certain wound care discharges from the site neutral payment rate for certain LTCHs.

Effective date: April 21, 2016

Implementation date: October 3, 2016

View Transmittal R1654OTN.

View MLN Matters article MM9599.

Submission for OMB Review; comment request

On May 2, CMS posted a notice in the Federal Register stating that it is accepting comments on: CMS–R-131, Advance Beneficiary Notice of Noncoverage (ABN); CMS–R-244, The PACE Organization (PO) Application Process in 42 CFR part 460. Comments are due June 1.

View the notice in the Federal Register.

Leave a comment.

Cornerstone Hospital incorrectly billed Medicare inpatient claims with Kwashiorkor

On May 2, the OIG posted a report stating that Cornerstone Hospital of Bossier City did not comply with Medicare requirements for billing Kwashiorkor on any of the 73 claims reviewed. The hospital used diagnosis code 260 for Kwashiorkor but should have billed for other forms of malnutrition. For 25 of the inpatient claims, substituting a more appropriate diagnosis code produced no change in the diagnosis-related group or payment amount. However, for the remaining 48 inpatient claims, the errors resulted in overpayments of $322,000. The hospital believes that all claims identified by the OIG were appropriately submitted for payment.

View the report.

Review of Tufts Medical Center claims that included medical device replacements

On May 2, the OIG posted a report stating that Tufts Medical Center complied with Medicare billing requirements for four of the 18 inpatient and outpatient claims reviewed. However, Tufts did not fully comply with Medicare billing requirements for the remaining 14 claims, resulting in overpayments of at least $118,000 for calendar years 2011 through 2014. These errors occurred primarily because Tufts staff (1) had inadequate education on inpatient level-of-care criteria and lacked documentation necessary to determine the appropriate level of service and (2) lacked the level of oversight and the coordination between departments to correctly report the device credits it received for warranted or recalled medical devices.

View the report.

OIG Advisory Opinion No. 16-05

On May 2, the OIG posted an advisory opinion in response to a request for an advisory opinion regarding the use of a “preferred hospital” network as part of Medicare Supplemental Health Insurance (“Medigap”) policies, whereby a facility would indirectly contract with hospitals for discounts on the otherwise-applicable Medicare inpatient deductibles for its policyholders and, in turn, would provide a premium credit of $100 to policyholders who use a network hospital for an inpatient stay.

View the opinion.

Scoresheet from Medicare Evidence Development and Coverage Advisory Committee (MEDCAC)

On May 2, CMS posted the scoresheet from the recent MEDCAC panel meeting, which was held to obtain recommendations regarding the definition of treatment resistant depression (TRD) in clinical research as well as advise CMS on the use of the definition of TRD in the context of coverage with evidence development and treatment outcomes.

View the scoresheet.

Privacy Act of 1974; Report of New System of Records (SOR)

On May 3, CMS posted a notice in the Federal Register stating that, in accordance with the requirements of the Privacy Act of 1974, CMS is proposing to establish a new SOR titled ‘‘CMS Risk Adjustment Data Validation System (RAD–V),’’ System No. 09–70–0511. Under § 1343 of the Patient Protection and Affordable Care Act (Pub. L. 111–148) as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111– 152), and the implementing regulations at 45 CFR part 153, data collected and maintained in this system will be used to support the audit functions of the risk adjustment program, including validation activities under the risk adjustment data validation program.

View the notice in the Federal Register.

Announcement of requirements and registration for the Merit-based Incentive Payment System (MIPS) mobile challenge

On May 3, CMS posted a notice in the Federal Register launching a challenge related to the new MIPS program, which will assist CMS in accelerating the transition from the traditional fee-for-service payment model to a system that rewards health care providers for giving better care, not just more care. This challenge will educate and provide outreach to the potential 1.2 million MIPS eligible clinicians.

View the notice in the Federal Register.

NCD for stem cell transplantation, formerly 110.8.1 (110.23)

On May 3, CMS posted a NCD regarding stem cell transplantation. It is clarifying that bone marrow and peripheral blood stem cell transplantation is a process which includes mobilization, harvesting, and transplant of bone marrow or peripheral blood stem cells and the administration of high dose chemotherapy or radiotherapy prior to the actual transplant. When bone marrow or peripheral blood stem cell transplantation is covered, all necessary steps are included in coverage. When bone marrow or peripheral blood stem cell transplantation is not covered, none of the steps are covered.

View the NCD.

Guidance to surveyors on federal requirements for providing services to justice involved individuals

On May 3, CMS posted a survey and certification letter clarifying requirements for providing services to justice involved individuals in SNFs, nursing facilities, hospitals, psychiatric hospitals, critical access hospitals, and intermediate care facilities for individuals with intellectual disabilities. Specifically, this guidance seeks to assure high quality care that is consistent with essential patient rights and safety for all individuals.

View the survey and certification letter.

Fire safety requirements for certain healthcare facilities

On May 4, CMS posted a final rule in the Federal Register amending the fire safety standards for Medicare and Medicaid participating hospitals, critical access hospitals, long-term care facilities, intermediate care facilities for individuals with intellectual disabilities, ASCs, hospices providing inpatient services, religious non-medical health care institutions, and programs of all-inclusive care for the elderly facilities. Further, this final rule will adopt the 2012 edition of the Life Safety Code and eliminate references in our regulations to all earlier editions of the Life Safety Code. It will also adopt the 2012 edition of the Health Care Facilities Code, with some exceptions. This rule is effective July 5.

View the notice in the Federal Register.

View the press release.

Revised method for calculating additional documentation request (ADR) limits

On May 4, CMS posted an update on the Recovery Audit Program webpage stating it has revised the method used to calculate ADR limits for institutional providers. A document describing the new methodology can be found in the “Downloads” section of the Provider Resource page.

View CMS’ Recovery Audit Program webpage.

View the document describing the new methodology

Updates to data initiatives increase transparency of the Medicare program

On May 5, CMS posted a press release discussing the publication of updated data to increase transparency in the Medicare program. CMS is posting the third annual release of the Physician and Other Supplier Utilization and Payment public use data. In addition, CMS is announcing the availability of more timely data for researchers.

View the press release.

July 2016 quarterly update HCPCS drug/biological code changes

On May 6, CMS released a transmittal informing the contractors of updating specific drug/biological HCPCS codes. New codes are listed in the transmittal.

Effective date: July 1, 2016

Implementation date: July 5, 2016

View Transmittal R3518CP.

Percutaneous left atrial appendage closure (LAAC)

On May 6, CMS released a change request informing contractors that it issued an NCD covering percutaneous left atrial appendage closure (LAAC) through coverage with evidence development when LAAC is furnished in patients with non-valvular atrial fibrilation and according to an FDA approved indication for percutaneous LAAC with an FDA-approved device.

Effective date: February 8, 2016

Implementation date: October 3, 2016

View Transmittal R3515CP.

View Transmittal R192NCD.

Corrections to Chapter 1 of the Medicare Claims Processing Manual

On May 6, CMS released a change request making various corrections to Chapter 1 of the Medicare Claims Processing Manual.

Effective date: August 8, 2016

Implementation date: August 8, 2016

View Transmittal R3519CP.

Shared Savings Program (SSP) Accountable Care Organization (ACO) qualifying stay edits

On May 6, CMS released a change request to allow SNF claims to be processed without having to meet the three-day hospital stay requirement for a select number of facilities that have a relationship with an SSP ACO.

Effective date: January 1, 2017

Implementation date: October 3, 2016, FISS to begin work.; January 3, 2017, full implementation.

View Transmittal R1660OTN.

Submission for OMB review; comment request

On May 6, CMS posted a notice in the Federal Register stating that it is accepting comments on: CMS–685, End Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations; CMS–576A, Organ Procurement Organization’s (OPOs) Health Insurance Benefits Agreement and Supporting Regulations; and CMS–10601, CMS Innovation Partners Program Applications and Comments are due June 6.

View the notice in the Federal Register.