This week in Medicare updates—5/8/19
Medicare Documentation Job Aid for Doctors of Chiropractic
On April 29, CMS published an MLN Tool regarding documentation techniques for chiropractic doctors. The tool serves as a model of information that these providers should include when receiving a request for documentation from a Medicare contractor, such as types of patient information, subluxation details, evaluation information, treatment plans, and subsequent visit details.
National Coverage Analysis (NCA) for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer
On April 29, CMS published a Tracking Sheet regarding an NCA for NGS coverage. CMS is reconsidering the evidence available for tests of germline mutations to identify those with hereditary cancer who may benefit from targeted treatments based on the result of those tests. The tracking sheet initiates a 30-day comment period on this NCA, which is strictly limited to these tests of germline mutations for hereditary cancer. The comment period will end on May 29, 2019.
Proposed Rule: Accrediting Organizations - Changes to Change of Ownership
On April 30, CMS published a draft version of a Proposed Rule intended to enhance CMS oversight of accrediting organizations when these organizations undergo a change of ownership. The rule would add requirements and a specified process to address changes of ownership, specifically as they relate to the sale, transfer, and/or purchase of accrediting organizations’ assets. This would enable CMS to receive notice when an accrediting organization is contemplating undergoing or negotiating a change of ownership and would enable CMS to review the accrediting organization’s ability to perform tasks after a change of ownership has occurred.
CMS published a Press Release on the proposed rule on the same date. Comments on this proposed rule are due no later than 5 p.m. on July 1, 2019. The rule was published in the Federal Register on May 2, 2019.
Risk Adjustment Data Validation
On April 30, CMS published an Extension of Comment Period in the Federal Register to announce that it will extend the comment period for the Risk Adjustment Data Validation (RADV) provisions of the Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit for Years 2020 and 2021 proposed rule, originally published in the Federal Register on November 1, 2018. The comment period for these provisions was originally scheduled to end on April 30, 2019, but CMS is extending it by 120 days to August 28, 2019. CMS is also releasing additional data underlying the FFS Adjuster Study released October 26, 2018.
Dates: The comment period for RADV provisions [section II.C.2. Of the proposed rule and proposed §§422.300, 422.310(e) and 422.311(a)] is further extended to 5 p.m. on August 28, 2019.
Update to Publication 100-08 to Provide Language-Only Changes for the New Medicare Card Project
On April 30, CMS published Medicare Program Integrity Transmittal 877, which rescinds and replaces Transmittal 876, dated April 12, 2019, to remove section 4.11 from Section II - Changes in Manual Instructions and the attached manual instructions because the section had been removed from the IOM by another CR. The original transmittal was issued regarding changes to the manual to update language related to the new Medicare cards.
Effective date: May 13, 2019
Implementation date: May 13, 2019
CMS Outlines Comprehensive Strategy to Foster Innovation for Transformative Medical Technologies
On May 2, CMS published a Press Release regarding two specific actions the administration is taking as part of a strategy to improve access to emerging technologies. First, CMS will change the process for issuing HCPCS codes by providing quarterly opportunities to apply for new codes for drugs and semi-annual opportunities to apply for devices. CMS is also clarifying its policy for Category III CPT codes for technologies that do not fall under an existing LCD. Medicare contractors are being instructed to follow the new LCD process for every local coverage decision, including reviewing evidence with respect to technology.
Local Coverage Determination (LCD) Process Modernization Q&As
On May 2, CMS published a Q&A on the recent updates to the LCD process made in an attempt to modernize the system. The questions address what new changes were made, why these changes were made, how the process complies with regulations from the 21st Century Cures Act, what the role and function of Contractor Advisory Committees should be, and more.
Updated Corporate Integrity Agreement Documents
On May 2, the OIG published information on a new Corporate Integrity Agreement with US WorldMeds, LLC and Solstice Neurosciences, LLC, of Louisville, Kentucky.
Trends in Deficiencies at Nursing Homes Show That Improvements are Needed to Ensure the Health and Safety of Residents
On May 2, the OIG published a Data Brief regarding nursing home deficiencies (defined as a nursing home’s failure to meet a federal participation requirement) that were identified by state survey agencies nationwide from CY 2013-2017. The OIG found that deficiencies increased slightly each year from 2013-2016 before a slight decrease in 2017, and only 6% of deficiencies had “more serious” ratings. Approximately 31% of nursing homes, however, had a repeat deficiency that was cited at least five times in separate surveys, and at least half of these nursing homes experienced an incident of a more serious deficiency. The results of the data analysis do not clearly indicate whether quality of care and services at nursing homes improved during the review period, and combined with a previous OIG report that found seven of nine state agencies did not always verify nursing homes’ correction of deficiencies, the OIG concludes that nursing homes might not be properly implementing systemic changes to ensure that deficiencies do not occur.
Some Diagnosis Codes that Essence Healthcare, Inc., Submitted to CMS Did Not Comply with Federal Requirements
On May 2, the OIG published a Report regarding whether Essence Healthcare, Inc., a Medicare Advantage organization, submitted appropriate diagnosis codes to CMS in compliance with regulations for CMS’ risk adjustment program. The OIG found that, for 75 of the 218 enrollee-years, the diagnosis codes for acute stroke and major depressive disorder were either not supported in the medical records (70) or could not be supported because Essence could not locate the medical records (5). As a result, Essence received $158,904 in overpayments for the 75 enrollee-years.
The OIG recommends Essence refund the $158,904 in overpayments, identify and return any similar instances of overpayments that occurred outside of the audit period, and enhance its policies and procedures to detect and correct noncompliance with federal requirements for diagnosis codes used to calculate risk-adjusted payments. Essence concurred with the OIG recommendations, but it also stated that there is no requirement that a major depressive disorder diagnosis be submitted multiple times during the year in order to be considered supported in the medical record. The OIG claimed it did not use the number of times a diagnosis code was submitted as a basis for any enrollee-year error and said it relied on the results of Essence’s own internal coding review. It therefore will not make any revisions to its findings or recommendations.
Draft Only - Guidance for Hospital Co-Location with Other Hospitals or Healthcare Facilities
On May 3, CMS published a Memorandum to state survey agency directors regarding a draft of guidance on hospital co-location. The guidance adds clarity as to how CMS and state agency surveyors will evaluate a hospital’s space sharing or contracted staff arrangements with another hospital or health care entity when assessing the hospital’s compliance with the Conditions of Participation.
CMS is seeking comment on these draft revised policies by July 2, 2019.
Provider Cost Reporting Forms and Instructions, Chapter 44, Form CMS-224-14
On May 3, CMS published Provider Reimbursement Manual Transmittal 3 regarding updates to Chapter 44 for the Federally Qualified Health Center Cost Report. The updates include revised instructions regarding requirements under the Paperwork Reduction Act of 1995, clarified headings in exhibit 1, revised elements of Worksheet E to include demonstration related adjustments in certain places, and more.
Effective date: Cost Reporting Periods ending on or after April 30, 2019
Systems Changes to Allow IPPS-Excluded Hospitals to Operate IPPS-Excluded Units
On May 3, CMS published One-Time Notification Transmittal 2293 regarding systems changes to allow Medicare systems to process payments to IPPS-excluded units of IPPS-excluded hospitals, as the Inpatient Rehabilitation Facility Prospective Payment System and Inpatient Psychiatric Facility Prospective Payment System show it is no longer redundant for an IPPS-excluded hospital to have an IPPS-excluded unit.
Effective date: October 1, 2019
Implementation date: October 7, 2019
Update to the Internet Only Manual (IOM) Publication 100-04, Chapter 4
On May 3, CMS published Medicare Claims Processing Transmittal 4295 regarding changes to manual instructions that will redefine the account of the HCPCS codes for TOB 85x.
Effective date: August 27, 2019
Implementation date: August 27, 2019
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
On May 3, CMS published Medicare Claims Processing Transmittal 4296 regarding the quarterly update to the clinical laboratory fee schedule. There are 20 new codes effective July 1, 2019, for Proprietary Laboratory Analysis tests.
Effective date: July 1, 2019
Implementation date: July 1, 2019
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - July 2019 Update
On May 3, CMS published Medicare Claims Processing Transmittal 4292 regarding quarterly updates to the MPFSDB. Changes include updates to procedure status indicators for multiple J and Q codes and new CPT codes for certain cardiac procedures, bone testing, anatomic modeling image sets, and more.
CMS published MLN Matters 11293 on the same date to accompany the transmittal.
Effective date: January 1, 2019
Implementation date: July 1, 2019
Common Working File (CWF) to Medicare Beneficiary Database (MBD) Extract File Changes to Send All Hospice Periods to Support HIPAA Eligibility Transaction System (HETS)
On May 3, CMS published One-Time Notification Transmittal 2285 regarding a system change to fix an error discovered through a previous hospice data redesign in the CWF. CMS is requesting that CWF separate the data from HOEP Auxiliary and HOSP AUX, and it requests that CWF send all Hospice Benefit Periods for a beneficiary on the CABEMBD extract irrespective of when it happened.
Effective date: October 1, 2019
Implementation date: October 7, 2019
Medicare Physician Fee Schedule Database File Record Layout
On May 3, CMS published Medicare Claims Processing Transmittal 4298 regarding revisions to field descriptions for some fields in the Medicare Physician Fee Schedule Database file record layout. The file record layout will also only be revised in future years when there is a change to a field rather than on an annual basis.
Effective date: January 1, 2019
Implementation date: October 7, 2019
FISS - Develop Enhanced Claims Search Reporting in FISS - Phase 2
On May 3, CMS published One-Time Notification Transmittal 2288 regarding phase two of a project to improve claim search capability in FISS. This phase will involve improvements to claim filtering functionality by adding new search fields, modifications to allow the claims summary screen to show claims in ascending or descending order by DCN, and more.
Effective date: October 1, 2019 - Requirements, Test Plan, and Coding; January 1, 2020 - Alpha Testing, Implementation, and Documentation
Implementation date: October 7, 2019 - Requirements, Test Plan, and Coding; January 6, 2020 - Alpha Testing, Implementation, and Documentation
ICD-10 and Other Coding Revisions to National Coverage Determinations
On May 3, CMS published One-Time Notification Transmittal 2298 regarding the continued update of ICD-10 conversions and other coding updates specific to NCDs as a result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Effective date: October 1, 2019 - Unless otherwise noted in requirements
Implementation date: October 7, 2019 - MAC local edits 60 days for issuance
Home Health Patient-Driven Groupings Model (PDGM) - Additional Manual Instructions
On May 3, CMS published Medicare Claims Processing Transmittal 4294 regarding manual updates related to the implementation of the PDGM model. These updates include changing language to the new periods of care, methods for using HIPPS codes to determine final payment for periods of care, how to bill for services provided during a period of care, and more.
Effective date: January 1, 2020 - Claim “From” dates on or after this date
Implementation date: August 7, 2019
Re-implementation of the AMCC Lab Panel Claims Payment System Logic
On May 3, CMS published Medicare Claims Processing Transmittal 4299 regarding changes to processes for laboratories reporting AMCC panel tests. Labs should report the HCPCS codes for the AMCC panel test where appropriate and should not report separately the tests that make up that panel.
CMS published MLN Matters 11248 on the same date to accompany the transmittal.
Effective date: January 1, 2019
Implementation date: October 7, 2019
Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process
On May 3, CMS published One-Time Notification Transmittal 2297 regarding changes to ensure the Part B shared system will no longer mask pre-March 1964 Railroad Retirement Board numbers when included on outbound COBA provider notification letters, and changes to ensure that a service facility location loop is created for 837 COB claims when the service facility location provider zip code is different from the bill-to-provider zip code.
Effective date: October 1, 2019
Implementation date: October 7, 2019
HIPAA Electronic Data Interchange (EDI) Front End Updates for October 2019
On May 3, CMS published One-Time Notification Transmittal 2287 regarding the October 2019 Common Edits and Enhancements Module (CEM) edits to the Part A and Part B MACs and the Common EDI contractor.
Effective date: October 1, 2019
Implementation date: October 7, 2019
Updating FISS for Pricing Drugs at Different Rates Depending on Provider Type
On May 3, CMS published One-Time Notification Transmittal 2296 regarding system changes to enable different payment rates for the same drug/biological depending on whether it is paid at the Outpatient Prospective Payment System rate or the End-Stage Renal Disease rate.
CMS published MLN Matters 11199 on the same date to accompany the transmittal.
Effective date: October 1, 2019
Implementation date: October 7, 2019
FISS Integrated Outpatient Code Editor (IOCE) Claim Return Buffer Interface Changes Related to New Return Code Field Updates
On May 3, CMS published One-Time Notification Transmittal 2294 regarding a new return code field in the claim return buffer table.
Effective date: April 1, 2019
Implementation date: October 7, 2019
ViPS Medicare System (VMS) - New Standard Paper Remittance (SPR) Files for Use on Durable Medical Equipment MACs Web Portals
On May 3, CMS published One-Time Notification Transmittal 2290 regarding a new process to generate facsimile SPRs corresponding to all Electronic Remittance Advices generated in the VMS. This will provide SPR files to the DME MACs for use on their web portals.
Effective date: October 1, 2019
Implementation date: October 7, 2019
Medicare Summary Notice (MSN) Changes to Assist Beneficiaries Enrolled in the Qualified Medicare Beneficiary (QMB) Program
On May 3, CMS published Medicare Claims Processing Transmittal 4290 regarding modifications to claims processing systems to ensure that MSNs appropriately differentiate between QMB claims that are paid and denied.
Effective date: October 1, 2019
Implementation date: October 7, 2019 - For claims processed on or after this date