This week in Medicare updates—2/27/2019
2020 Hospital Outpatient Payment Panel OPPS Cost Statistics Two Times Run Document
On February 19, CMS published a Document containing the 2020 OPPS panel two times file to provide cost statistic information on services as organized by their ambulatory payment classification (APC).
CMS Launches Podcast to Reach Stakeholders via Modern Platform
On February 19, CMS published a Press Release to announce its new podcast, “CMS: Beyond the Policy.” The podcast will highlight updates and changes to policies, and the first episode focuses on changes to evaluation and management coding.
Comparison of Average Sales Prices and Average Manufacturer Prices: Results for the Third Quarter of 2018
On February 20, the OIG published a Review of how average sales prices compare to average manufacturer prices for Part B drugs in the third quarter of 2018. The OIG found that nine drug codes met CMS’ price substitution criteria by exceeding the 5% threshold for two consecutive quarters or three of the previous four quarters. It is sending those nine codes to CMS for review.
CMS Improperly Paid Millions of Dollars for Skilled Nursing Facility (SNF) Services When the Medicare 3-Day Inpatient Hospital Stay Requirement Was Not Met
On February 20, the OIG published a Review of whether CMS paid SNF claims with dates of service from 2013 through 2015 when the three-day stay requirement was not met. The OIG found that CMS improperly paid 65 of the 99 SNF claims sampled. Based on those results, the OIG estimates CMS improperly paid $84 million for SNF services that did not meet the three-day rule during CYs 2013-2015. These improper payments were due to the absence of coordinated notification mechanism among hospitals, beneficiaries, and SNFs to ensure compliance with the three-day rule. CMS also allowed SNF claims to bypass the CWF qualifying stay edit during the audit period, so SNF claims were not matched with associated hospital claims that reported inpatient stays of fewer than three days.
The OIG recommends that CMS ensure the CWF qualifying inpatient stay hospital edit for SNF claims is enabled when SNF claims are processed for payment. It also recommends CMS provide beneficiaries with written notification of the number of inpatient days of care provided during the hospital stay and whether that qualifies for subsequent SNF care. CMS should require SNFs to obtain written notification from the hospital and retain it as a condition of payment for claims. The OIG also recommends CMS educate hospitals and SNFs about verifying and documenting three-day inpatient hospital stays relative to Medicare claims for SNF reimbursement.
Update to Chapter 15 of Publication (Pub.) 100-08
On February 21, CMS published Medicare Program Integrity Transmittal 865, which rescinds and replaces Transmittal 862, dated February 8, 2019, to remove the MLN article requirement, remove the new section 15.30, and remove the change to the table of contents. The original transmittal was issued regarding several changes to provider enrollment policies.
Effective date: March 12, 2019
Implementation date: March 12, 2019
Ensuring Organ Acquisition Charges Are Not Included in the Inpatient Prospective Payment System (IPPS) Payment Calculation
On February 21, CMS published One-Time Notification Transmittal 2262, which rescinds and replaces Transmittal 2235, dated January 25, 2019, to exclude revenue codes 0815 and 0819 (used to report stem cell acquisition services) for which payment is included in the MS-DRG payment. The original transmittal was issued to ensure that organ acquisition costs are not included in the IPPS payment calculation for claims that group to a non-transplant MS-DRG.
On February 22, CMS published a revised MLN Matters 11087 to accompany the transmittal.
Effective date: July 1, 2019
Implementation date: July 1, 2019
Comment Request: Reassignment of Medicare Benefits; Important Message from Medicare; more
On February 22, CMS published a Comment Request in the Federal Register regarding the following information collections:
- Reassignment of Medicare Benefits
- End Stage Renal Disease Death Notification
- End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration
- Hospital Notices: IM/DND
Comments on these information collections are due by April 23, 2019.
Updating Limitation on Recoupment; Medicare Overpayments Manual
On February 22, CMS published Medicare Financial Management Transmittal 311 regarding changes to the manual applicable to contractor recoupment of overpayments. These changes address timelines for recoupment, payment suspensions relating to limitations on recoupment, redetermination receipts, and more.
Effective date: October 7, 2019 - This date is due to a HIGLAS enhancement
Implementation date: October 7, 2019 - This date is due to a HIGLAS enhancement
HCPCS Codes Subject To and Excluded From Clinical Laboratory Improvement Amendments (CLIA) Edits
On February 22, CMS published Medicare Claims Processing Transmittal 4245 regarding the new HCPCS codes for 2019 that are subject to and excluded from CLIA edits. There is an extensive list of new codes for 2019 that are included in the transmittal, many of which are related to genetic analysis.
Effective date: January 1, 2019
Implementation date: April 1, 2019
Update Regarding Audits by UPICs
On February 22, CMS published Medicare Program Integrity Transmittal 868 to update the manual to state that the Unified Program Integrity Contractor should take any appropriate investigative actions within 180 calendar days unless otherwise specified by CMS.
Effective date: March 25, 2019
Implementation date: March 25, 2019
Evaluation and Management (E/M) When Performed with Superficial Radiation Treatment
On February 22, CMS published Medicare Claims Processing Transmittal 4246 regarding revisions to the manual to allow for billing E/M codes for levels I through III in order to report physician work associated with radiation therapy planning, radiation treatment device construction, and radiation treatment management when performed on the same date of service as superficial radiation treatment delivery.
Effective date: January 1, 2019
Implementation date: March 25, 2019