The week in Medicare updates
National Coverage Determination (NCD) for Single Chamber and Dual Chamber Permanent Cardiac Pacemakers
On July 10, CMS released a change request stating that, effective for claims with dates of service on or after August 13, 2013, contractors shall allow payment for nationally covered implanted permanent cardiac pacemakers, single chamber or dual chamber, for the indications outlined in Pub. 100-03 Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.8.3.
Effective date: August 13, 2013
Implementation date: To Be Determined
View Transmittal R2986CP.
View Transmittal R170NCD.
View MLN Matters article MM8525.
Provider Reimbursement Manual Part 1, Chapter 25, Limitation on Coverage of Costs under Medicare and Notice of Schedule of Limits on Provider Costs
On July 11, CMS issued a transmittal to notify the public of changes to the Provider Reimbursement Manual, including multiple deletions of obsolete items. All of the policies set forth in this chapter are obsolete because payments to hospitals, skilled nursing facilities, and home health agencies on a reasonable cost basis that are subject to cost limits have been replaced by payments based on prospective payment systems (PPS). PPS for hospitals was implemented for cost reporting periods beginning on and after October 1, 1983, for skilled nursing facilities for cost reporting periods beginning on and after July 1, 1998 and for home health agencies for cost reporting periods beginning on and after October 1, 2000. Chapter 25 will be reserved for future use.
Effective date: July 11, 2014
View Transmittal R463PRM.
Medicare Part A Skilled Nursing Facility (SNF) PPS Pricer Update FY 2015
On July 11, CMS issued an attachment that provides information on the updates to the payment rates used under the PPS for SNFs, for FY 2015, as required by statute. The update can be found in Chapter 6, Section 30.7 of the Claims Processing Manual.
Effective date: October 1, 2014
Implementation date: October 6, 2014
View Transmittal R2985CP.
View MLN Matters article MM8828.
Beneficiary signature requirements for ambulance services
On July 11, CMS issued change requests on this matter. The first removes the requirement that a representative provide his/her address when signing for ambulance services on behalf of a beneficiary. This applies to Pub. 100-04, Medicare Claims Processing, Chapter 1, Section 50.1.3, and Chapter 26, Section 10.3, Item 12. It also applies to Pub. 100-02, Medicare Benefit Policy Manual. The second corrects the timeframe for filing a Medicare claim from 15-27 months to 12 months in the Benefit Policy Manual to conform with the policy information in Pub. 100-04, Medicare Claims Processing Manual, Chapter 10, section 20.1.2.
Effective date: August 12, 2014
Implementation date: August 12, 2014
View Transmittal R2984CP.
View Transmittal R190BP.
Notice of new interest rate for Medicare overpayments and underpayments for FY 2014 4th quarter
On July 11, CMS released a notice stating that Medicare Regulation 42 CFR Section 405.378 provides for the charging and payment of interest on overpayments and underpayments to Medicare providers. The Secretary of Treasury certifies an interest rate quarterly. Treasury utilizes the most comprehensive data available on consumer interest rates to determine the certified rate. Interest is assessed on delinquent debts in order to protect the Medicare Trust Funds. The attached Recurring Update Notification applies to Pub. 100-06, Medicare Financial Management Manual, Chapter 3, Section 10.
Effective date: July 18, 2014
Implementation date: July 18, 2014
View Transmittal R237FM.
Hospital Outpatient Prospective Payment and Ambulatory Surgical Center (ASC) Payment Systems and Quality Reporting Programs
On July 14, CMS posted a proposed rule in the Federal Register that would revise the OPPS and ASC payment system for CY 2015 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this proposed rule, proposed changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and ASC payment system are described. In addition, this rule would update and refine the requirements for the Hospital Outpatient Quality Reporting Program and the ASC Quality Reporting Program. There are also proposed changes to the data sources used for expansion requests for physician owned hospitals under the physician self-referral regulations; the underlying authority for the requirement of an admission order for all hospital inpatient admissions and changes to require physician certification for hospital inpatient admissions only for long-stay cases and outlier cases; and to establish a three-level appeals process for Medicare Advantage organizations and Part D sponsors that would be applicable to CMS-identified overpayments associated with data submitted by these organizations and sponsors. Comments are due September 2.
View the notice in the Federal Register.
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Implementation of a PPS for Federally Qualified Health Centers (FQHCs)
On July 16, CMS released a change request to implement the FQHC PPS. Section 10501(i)(3)(A) of the Affordable Care Act (Pub. L. 111-148 and Pub. L. 111-152) added section 1834(o) of the Social Security Act to establish a new system of payment for the costs of FQHC services under Medicare Part B based on prospectively set rates. The statute requires implementation for FQHCs with cost reporting periods beginning on or after October 1, 2014.
Effective date: October 1, 2014
Implementation date: October 6, 2014
View Transmittal R1395OTN.
Cardiac Rehabilitation Programs for Chronic Heart Failure
On July 18, CMS released a change request that is effective for dates of service on and after February 18, 2014 to expand Medicare coverage for cardiac rehabilitation services to beneficiaries with stable, chronic heart failure, defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms, despite being on optimal heart failure therapy for at least 6 weeks.
Effective date: February 18, 2014
Implementation date: August 18, 2014
View Transmittal R530PI.
View Transmittal R2989CP.
View Transmittal R191BP.
View Transmittal R171NCD.
Quarterly Update to 2014 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing Enforcement
On July 18, CMS released a notification that provides updates to the lists of HCPCS codes that are subject to the consolidated billing provisions of the SNF PPS. Changes to CPT/HCPCS codes and Medicare Physician Fee Schedule designations will be used to revise CWF edits to allow MACs to make appropriate payments in accordance with policy for SNF consolidated billing in Pub. 100-04, Medicare Claims Processing Manual, Chapter 6, section 20.6.
Effective date: January 1, 2014
Implementation date: October 6, 2014
View Transmittal R2991CP.
October 2014 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
On July 18, CMS released a change request regarding the ASP payment methodology, which is based on quarterly data submitted to CMS by manufacturers. CMS will supply contractors with the ASP and not otherwise classified drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the OPPS are incorporated into the Outpatient Code Editor (OCE) through separate instructions that can be located in Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, section 50.
Effective date: October 1, 2014
Implementation date: October 6, 2014
View Transmittal R2990CP.
View MLN Matters article MM8836.
New Waived Tests
On July 18, CMS released a change request to inform contractors of new CLIA waived tests approved by the FDA. Since these tests are marketed immediately after approval, CMS must notify contractors of the new tests so that they can accurately process claims. There are 25 newly added waived complexity tests. The initial release of this Recurring Update Notification applies to Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, section 70.8.
Effective date: October 1, 2014
Implementation date: October 6, 2014
View Transmittal R2988CP.
View MLN Matters article MM8805.