This week in Medicare updates – 1/31/18

CMS Advanced Alternative Payment Model (APM) Determination Process Fact Sheets

On January 23, CMS published two fact sheets regarding Other Payer Advanced APM Determination processes. One fact sheet covers the processes for Medicare Health Plans, and the other fact sheet covers the processes for CMS Multi-Payer Models. Both fact sheets also provide information on:

• The All-Payer Combination Option for participating in the Quality Payment Program (QPP) as an APM
• The Other Payer Advanced APM Determination Process
• The Payer Initiated Process for submitting information on payment arrangements
• The Eligible Clinician Initiated Process for submitting information on payment arrangements

 

Expired Medicare Legislative Provisions, including Therapy Caps and Exception Process

On January 23, CMS published a Notice for all Fee-For-Service Providers regarding Medicare legislative provisions that have recently expired, including exceptions to the outpatient therapy caps, the Medicare physician work geographic adjustment floor, add-on payments for ambulance services and home health rural services, payments for low volume hospitals, and payments for Medicare dependent hospitals. CMS will implement the payment policies as required under current law.

CMS is also taking steps to limit the impact on Medicare beneficiaries by holding claims affected by the therapy caps exceptions process expiration for a short period of time beginning on January 1, 2018. CMS will only hold therapy claims containing the KX modifier. If claims are submitted without the KX modifier and the beneficiary has exceeded the cap, the claim will be denied. If legislation is not enacted regarding the therapy caps in a short period of time, CMS will release and process the therapy claims accordingly.

Hospital providers, except CAHs, are not affected by the end of the therapy cap exception process. Therapy caps applied to PPS hospitals from October 2012 - December 2017 through legislation adopted by Congress. The therapy cap application to PPS hospitals expired at the same time the exception process expired.  Because the therapy caps no longer apply to PPS hospitals, arguably, they would no longer bill with the KX modifier. Hospitals should monitor this carefully though because CMS’ edits may not have been fully corrected to allow payment to hospitals without the KX modifier.  Hospital may wish to seek additional guidance from their MAC. Note, the caps still apply to CAHs through a separate regulation adopted by CMS.

 

Medicare Compliance Review of Carolinas Medical Center

On January 23, the OIG published a Report regarding Carolinas Medical Center’s compliance with select Medicare billing requirements. The OIG found Carolinas did not comply with Medicare billing requirements for 83 of the 240 reviewed inpatient claims, resulting in $1.7 million in estimated overpayments during the audit period running from January 1, 2014 to December 31, 2015. Of the 83 claims containing errors, 50 of those errors were due to incorrect diagnosis-related group (DRG) codes, 29 of those errors were due to incorrectly billing for patient discharges that should have been billed as transfers to home health services, and eight of those errors were due to incorrectly billed same-day readmissions that should have been combined with initial hospital stays.  

Carolinas disagreed with some of the OIG’s findings and stated it has a strong compliance program and developed comprehensive policies, procedures, education, auditing and other initiatives. In response, the OIG maintained that the report’s findings were valid.

 

Quality Reporting Programs: Approaching Submission Deadlines

On January 25, CMS published a Notice in MLN Connects regarding approaching submission deadlines for certain quality reporting programs. The programs and their approaching deadlines include:

• Inpatient Rehabilitation Facility Quality Reporting Program - February 15
• Long-Term Care Hospital Quality Reporting Program - February 15
• Skilled Nursing Facility Quality Reporting Program - May 15

 

Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process

On January 25, CMS issued One-Time Notification Transmittal 2022, which rescinds and replaces Transmittal 1971, dated November 9, 2017, regarding the Part B shared system’s suppression of duplicate diagnosis code pointers on coordination of benefits claims. The new transmittal was issued to modify requirement 10292.2.1 to change some wording and spacing as well as to explain the priority order of N699, N700, and N701. CMS is also modifying 10292.4 to ensure that the Multi-Carrier System (MCS) will not output zero dollar monetary amounts when Claim Adjustment Reason Code (CARC) 237-related Remittance Advice Remark Codes (RARCs) do not apply.

Effective date: April 1, 2018

Implementation date: April 2, 2018

 

Revisions to State Operations Manual (SOM) Appendix G, Guidance for Surveyors: Rural Health Clinics

On January 26, CMS issued State Operations Provider Certification Transmittal 177 regarding revisions to Appendix G of the SOM. These revisions include an additional survey process component, reorganization of the regulatory text and associated guidance into separate sections with a unique “tag” number, and improved clarity and precision of interpretive guidance and survey procedures.

Effective date: January 26, 2018

Implementation date: January 26, 2018

 

Updates to the Common Working File (CWF) to Allow Entry Code 9 Durable Medical Equipment (DME) Claims to Process Correctly

On January 26, CMS issued One-Time Notification Transmittal 2015 to instruct the CWF maintainer to bypass additional edits on submitted entry code 9 DME claims and not update the Certificate of Medical Necessity (CMN) auxiliary file or any other auxiliary file when entry code 9 DME claims are processed.

Effective date: July 1, 2018 - The effective date is the process date

Implementation date: July 2, 2018

 

Request for Nominations to the Advisory Panel on Hospital Outpatient Payment

On January 26, CMS published a Notice in the Federal Register to request nominations to fill vacancies on the Advisory Panel on Hospital Outpatient Payment. CMS is looking to fill up to four vacancies on the panel. Nominations should be sent to APCPanel@cms.hhs.gov. CMS will accept nominations on a continuing basis.

 

Identifying Prior Hospice Days When Calculating Hospice Routine Home Care Payments After a Transfer

On January 26, CMS issued One-Time Notification Transmittal 2014 to correct the number of days used to determine the 60 days of high routine home care payments on hospice claims. The change request ensures the count includes the days provided by another hospice when there is a transfer during a benefit period.

Effective date: January 1, 2016

Implementation date: July 2, 2018

 

Global Surgical Days for Critical Access Hospital (CAH) Method II

On January 26, CMS issued One-Time Notification Transmittal 2013 to implement the global surgical days for Method II CAH providers. These global surgical periods will mirror the logic historically applied to physicians and non-physician practitioners who bill their own services to the Multi-Carrier System (MCS).

Effective date: July 1, 2018

Implementation date: July 2, 2018

 

Updates to Common Working File (CWF) Edits for Acute Kidney Injury (AKI) Claims

On January 26, CMS issued One-Time Notification Transmittal 2017 to instruct the Shared System Maintainer to bypass edit 5715, which indicates the claim has an incorrect comorbid return code, on AKI claims.

Effective date: January 1, 2017

Implementation date: July 2, 2018