This week in Medicare updates–5/10/2017
Notice of Proposed Regulation Changes to Requirements Related to Survey Team Composition and Investigation of Complaints
On April 28, CMS posted a Memorandum regarding the FY 2018 Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNF) Proposed Rule. In the rule, CMS proposed changes including:
- Revision of the definitions of “complaint survey” and “abbreviated standard survey”
- Relocation of requirements related to complaint surveys
- Revision of survey team composition requirements
April 2017 Medicare Quarterly Provider Compliance Newsletter Released
On May 1, CMS released its April 2017 Medicare Quarterly Provider Compliance Newsletter (Volume 7, Issue 3). The issue addresses common Recovery Auditor and Comprehensive Error Rate Testing (CERT) findings that impact physicians, laboratories, End Stage Renal Disease facilities, Skilled Nursing Facilities, and others.
Two New “K” Codes for Therapeutic Continuous Glucose Monitors
On May 1, CMS published MLN Matters 10013 related to Transmittal 3751, dated April 21, 2017. The transmittal facilitates implementation of CMS Ruling 1682-R, which was issued on January 12, 2017, that the following two codes for therapeutic continuous glucose monitors will be added to the HCPCS code set effective July 1, 2017.
Effective date: July 1, 2017
Implementation date: July 3, 2017
New Physician Specialty Code for Advanced Heart Failure and Transplant Cardiology, Medical Toxicology, and Hematopoietic Cell Transplantation and Cellular Therapy
On May 1, CMS published MLN Matters 9957 related to Transmittal 3762 and Transmittal 283, both dated April 28, 2017. The transmittals are regarding two newly established physician specialty codes for Advanced Heart Failure and Transplant Cardiology (C7), Medical Toxicology (C8), and Hematopoietic Cell Transplantation and Cellular Therapy (C9).
Effective date: October 1, 2017
Implementation date: October 2, 2017
Update FISS Editing to Include the Admitting Diagnosis Code Field
On May 1, CMS published MLN Matters 9753 related to Transmittal 1832, dated April 28, 2017, regarding the update of logic in the Fiscal Intermediary Shared System (FISS) to allow editing of the admitting diagnosis field.
Effective date: October 1, 2017
Implementation date: October 2, 2017
Payment for Moderate Sedation Services Furnished with Colorectal Cancer Screening Tests
On May 1, CMS published MLN Matters 10075 related to Transmittal 3763, dated 28. The transmittal is regarding the payment of moderate sedation services furnished in conjunction with screening colonoscopy services for which the beneficiary should not be charged the coinsurance or deductible.
Effective date: January 1, 2017
Implementation date: October 2, 2017
Implementing the remittance advice messaging for the 20-hour weekly minimum for Partial Hospitalization Program services.
On May 1, CMS published MLN Matters 9880 related to Transmittal 1833, dated April 28, which implements remittance advice messaging that conveys supplemental and educational information to the provider submitting claims for Partial Hospitalization Program services where the patient did not receive the minimum 20 hours per week of therapeutic services his plan of care indicates is required, on claims with line item date of service (LIDOS) on or after October 1, 2017.
Effective date: October 1, 2017
Implementation date: October 2, 2017
Comment Request: Annual MLR and Rebate Calculation Report and MLR Rebate Notices
On May 2, CMS published a Comment Request on the Annual MLR and Rebate Calculation Report and MLR Rebate Notices information collection in the Federal Register.
July Quarterly Update for 2017 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule
On May 3, CMS published MLN Matters 10071 related to Transmittal 3760, dated April 28, 3017. The transmittal is regarding the update of the fee schedule and implements fee schedule amounts for new codes and corrects any fee schedule amounts for existing codes.
Effective date: July 1, 2017
Implementation dates: July 3, 2017
New Civil Monetary Penalties and Affirmative Exclusions
On May 3, the OIG published several new Civil Monetary Penalties and Affirmative Exclusions:
- Hartford Hospital in Connecticut entered into a $2,469,374 settlement agreement to resolve allegations that Hartford submitted claims where patients received home health services within three days of the patients' release from Hartford that were improperly coded as discharged rather than as a post-acute care transfer.
- Midstate Medical Center in Connecticut entered into a $436,748 settlement agreement with OIG to resolve allegations that Midstate submitted claims where patients received home health services within three days of the patients' release from Midstate that were improperly coded as discharged rather than as a post-acute care transfer.
- Frontera Strategies, LP, of Texas entered into a $510,938.74 settlement agreement to resolve allegations that Frontera submitted claims to Medicare for nerve conduction studies (NCS) that are considered screening exams and not covered by Medicare. Medicare Administrative Contractor Local Coverage Determinations specified that an electromyography must be performed as well as NCS for diagnostic purposes.
The OIG also updated its list of Corporate Integrity Agreements to include:
- Bay Area Sleep Associates, LLC, and SomnoMedics of Tampa, FL
- Roman, Charles P., DO, and Roman, Charles P., DO, PC, of Columbus, GA
Medicare Compliance Review of Mount Sinai Hospital for 2012 and 2013
On May 3, the OIG published a Report on its Medicare Compliance Review of Mount Sinai Hospital for 2012 and 2013. Mount Sinai Hospital of New York, New York, did not comply with Medicare billing requirements for 110 of 261 claims reviewed. The OIG estimates the hospital received overpayments totaling at least $41.9 million for the audit period.
Screening for Hepatitis B Virus (HBV) Infection
On May 4, CMS published MLN Matters 9859 related to Transmittal 195 and Transmittal 3761, both dated April 28, 2017. The transmittals are regarding CMS’ determination that, effective September 28, 2016, screening for HBV infection will be covered with the appropriate FDA approved/cleared laboratory tests, used consistent with FDA-approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations.
Effective date: September 28, 2016
Implementation dates: October 2, 2017 - for design and coding; January 1, 2018 - Testing and Implementation
Updated Provider Self-Disclosure Settlements
On May 4, the OIG published multiple Updated Provider Self-Disclosure Settlements, including:
- Madison Parish Hospital Service District d/b/a Madison Parish Hospital (MPH), of Louisiana, which agreed to pay $1,800,000 for allegedly violating the Civil Monetary Penalties Law, including provisions applicable to physician self-referrals and kickbacks for allegedly (1) improperly submitting claims to Medicare related to certain inpatient admissions; (2) receiving remuneration in the form of inpatient Computed Tomography equipment and services provided below fair market value from an independent diagnostic testing facility and paid remuneration to the IDTF in the form of below medical office space and support services; and (3) improperly reporting illegal remuneration from hospital vendors paid to a former CEO on MPH cost reports then used by the Medicare and Medicaid program to calculate reimbursement rates to MPH, resulting in overpayments.
- Samaritan Pacific Health Services, Inc., of Oregon, which agreed to pay $263,700 for allegedly violating the Civil Monetary Penalties Law provisions applicable to physician self-referrals and kickbacks for allegedly paying remuneration to a medical practice in the form of office space use without a written lease or payment of rent. In addition, Samaritan North Lincoln Hospital of Oregon, agreed to pay $60,300 for similar alleged violations of the Civil Monetary Penalties Law provisions applicable to physician self-referrals and kickbacks.
- David Yoon, MD, and Primary Care Physicians, Inc., of Florida, agreed to pay $379,085 for allegedly violating the Civil Monetary Penalties Law by submitting false claims to Medicare for services rendered by providers who were not enrolled in the Medicare program and services rendered by non-physician providers as "incident to" when the "incident to" requirements under Medicare were not met.
- Pafford Medical Services, Inc., of Arkansas, which agreed to pay $390,587.18 for allegedly violating the Civil Monetary Penalties Law when it allegedly employed an individual that it knew or should have known was excluded from participation in federal healthcare programs.
- Custom Clinic, PA, d/b/a Smart Clinic, of, Minnesota, which agreed to pay $24,696.18 for allegedly violating the Civil Monetary Penalties Law after allegedly submitting Chronic Care Management services under CPT Code 99490 that were not provided or that were not provided as required by CPT Code 99490.
- Allergy Partners, PA, of North Carolina, which agreed to pay $14,638.50 for allegedly violating the Civil Monetary Penalties Law for allegedly submitting Medicare claims for allergen immunotherapy injections provided without the requisite physician supervision.
- The University of Illinois, which agreed to pay $39,405.05 for allegedly violating the Civil Monetary Penalties Law when it allegedly improperly billed neurosurgical procedures in the name of a physician who was not the appropriate physician to bill for the services.
OIG Report: CMS Validated Hospital Inpatient Quality Reporting Program Data but Should Use Additional Tools to Identify Gaming
On May 5, the OIG published a Report, CMS Validated Hospital Inpatient Quality Reporting Program Data but Should Use Additional Tools to Identify Gaming, regarding its study of CMS’ Hospital Inpatient Quality Program. The OIG found that CMS met its regulatory requirement by validating sufficient IQR data in 2016, which are used to adjust payments on the basis of quality. Almost 99% of hospitals that CMS reviewed passed validation, and CMS took action against the six that failed, including reducing their Medicare payments. However, CMS' approach to selecting hospitals for validation for payment year 2016 made it less likely to identify gaming of quality reporting and CMS did not include any hospitals in its sample on the basis of their having aberrant data patterns.
April Quarterly Update for 2017 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule
On May 5, CMS published Transmittal 3768, which rescinds and replaces Transmittal 3729, dated March 3, 2017, to delete example text in the policy section.
Effective date: April 1, 2017
Implementation date: April 3, 2017
Comment Request: Medicare/Medicaid Psychiatric Hospital Survey Data and Supporting Regulations
On May 5, CMS posted a Comment Request in the Federal Register regarding Form CMS–724, which is used to collect data that assists CMS in program planning and evaluation and in maintaining an accurate database on providers participating in the psychiatric hospital program.
Screening for the Human Immunodeficiency Virus (HIV) Infection
On May 5, CMS published Transmittal 3766 to inform contractors that they shall recognize the specified HCPCS codes for services related to the Screening for the HIV Infection.
Effective date: April 13, 2015
Implementation date: October 2, 2017
Outlier Limitation on Outpatient Prospective Payment System (OPPS) Community Mental Health Centers (CMHC) Services
On May 5, CMS re-communicated Transmittal 1705, originally dated August 5, 2016, as it is is no longer sensitive. The transmittal implements an outlier limitation on OPPS CMHC Services. CMHC claims will be subject to an agency-level outlier cap such that in any given calendar year, an individual CMHC provider will receive no more than 8% of its total CMHC OPPS payments in outlier payments.
Effective date: January 1, 2017
Implementation dates:
January 3, 2017 - for BRs 1 through 10
April 3, 2017 - for BRs 11 through 12
Scribe Services Signature Requirements
On May 5, CMS published Transmittal 713 to provide instruction regarding signature requirements when scribe services are used by a physician/non-physician practitioner (NPP). CMS is adding language in the Medicare Program Integrity Manual to address the review of claims when scribes are used, which was not previously addressed.
Effective date: June 6, 2017
Implementation date: June 6, 2017
Analysis for Common Working File (CWF) to Medicare Beneficiary Database (MBD) Extract File Changes for Detailed Skilled Nursing Facility (SNF) Data to Support HIPAA Eligibility Transaction System (HETS) 1002
On May 5, CMS published Transmittal 1843 to perform analysis for modifying the CWF to MBD extract file to separate Medicare Part A spell data into its component stays to facilitate the reporting of Medicare beneficiary eligibility benefit details via the HETS. Currently, the CWF to MBD extract file sends Medicare Part A spell data as an aggregate of both hospital and SNF care, without distinguishing what amount of time or what providers were involved in the beneficiary’s stay.
Effective date: October 1, 2017
Implementation date: October 2, 2017
Modifications to the Common Working File (CWF) In Support of the Coordination of Benefits Agreement (COBA) Crossover Process
On May 5, CMS published Transmittal 3765 to separate the CWF system's exclusion logic for monetary/statistical adjustment claims from its logic for selection of voided/cancelled institutional claims and ensure that CWF is marking Medicaid Quality Project claims consistently within the Health Insurance Master Record claims history.
Effective date: October 1, 2017
Implementation date: October 2, 2017
Medicare Fee-for-Service Recovery Audit Contractor (RAC) Data Centers
On May 5, CMS published Transmittal 1841 regarding the next round of Medicare RAC contracts for the five different regions. The RACs in Regions 1-4 will perform postpayment review to identify and correct Medicare claims that contain improper payments (overpayments or underpayments) that were made under Part A and Part B, for all provider types other than Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Home Health/Hospice. The Region 5 RAC will be dedicated to the postpayment review of DMEPOS and Home Health/Hospice claims nationally. The jurisdictions for the RAC Regions 1-5 vary from the previous Regions A-D, therefore, the MACs will need to establish and test connectivity with their respective RAC regions.
Effective date: June 6, 2017
Implementation date: June 6, 2017
Update FISS Editing to Include All Three Patient Reason for Visit Code Fields
On May 5, CMS published Transmittal 1840 and MLN Matters 9672 to update logic in the Fiscal Intermediary Shared System (FISS) to allow editing of the expanded Patient Reason for Visit (PRV) fields.
Effective date: January 1, 2018 - Claims received on or after
Implementation dates:
October 2, 2017 - For requirements and design
January 8, 2018 - For testing and implementation