This week in Medicare updates—12/11/2019
Opioid Treatment Programs (OTP) Medicare Billing and Payment Fact Sheet
On December 2, CMS published an MLN Fact Sheet regarding billing and payment information for providers furnishing OTP services. The fact sheet discusses which services are covered, eligibility requirements for providers, methods for checking beneficiary eligibility for these services, and all coding and billing information necessary to include on claims when billing for OTPs.
Clinical Laboratory Fee Schedule (CLFS): CY 2020 Final Payment Determinations
On December 2, CMS published the Downloadable File for the CY 2020 CLFS Final Test Codes Payment Determinations. This file is available on CMS’ CLFS Annual Public Meeting webpage under the Payment Determination heading.
Electronic Form CMS-10455, Report of a Hospital Death Associated with Restraint or Seclusion
On December 2, CMS published a Memorandum to state survey agency directors regarding an electronic form that will replace the paper version of Form CMS-10455. This electronic form is available starting December 2, 2019, and CMS will accept either the paper or electronic version until December 31, 2020. Exclusive use of the electronic form will begin January 1, 2020. The memo also details information that must be included on the form and contains a link to the form itself.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state/regional office training coordinators within 30 days of this memorandum.
Fiscal Year 2019 Fall Semiannual Report to Congress
On December 2, the OIG published the Fall 2019 Semiannual Report to Congress regarding HHS OIG activities for all of 2019 and specific achievements from the second half of the fiscal year. The report notes that for FY 2019, the OIG discovered $5.04 billion in expected investigative recoveries, made 2,640 exclusions, and identified potential savings of $836,422,000.
The OIG published a Press Release on the report on the same date.
Medicare Hospital Provider Compliance Audit: Carolinas Hospital
On December 3, the OIG published a Review of whether Carolinas Hospital complied with Medicare requirements for billing inpatient and outpatient services for claims dating from January 1, 2016 through December 31, 2017. The review was focused on risk areas identified by prior OIG audits at other hospitals, and it found that Carolinas did not comply with Medicare billing requirements for 45 of the 100 claims included in the sample. Of those 45 claims, 41 were inpatient claims and four were outpatient claims. The issues discovered involved inpatient rehabilitation claims not meeting coverage requirements (22 claims), inpatient Part A claims that should have been billed as outpatient or outpatient with observation (15 claims), incorrect coding (four inpatient claims with incorrect DRGs, one outpatient claim with inappropriate use of the -XE modifier), and outpatient claims subject to consolidated billing (three claims). On the basis of this sample, the OIG estimated that Carolinas received overpayments of at least $3.4 million for the audit period.
The OIG recommends Carolinas refund the Medicare contractor at least $3.4 million, identify and return any similar overpayments, and strengthen controls to ensure full compliance with Medicare requirements. Carolinas disagreed with the OIG’s findings for the 22 inpatient rehabilitation claims and the 15 Part A claims involving observation, as it stated the OIG reviewer misunderstood the two-midnight rule and applied the wrong standards for medical necessity of inpatient rehabilitation. The OIG, however, maintained that all of its findings and recommendations were correct.
Medicare Hospital Provider Compliance Audit: Northwest Medical Center
On December 3, the OIG published a Review of whether Northwest Medical Center complied with Medicare requirements for billing inpatient and outpatient services for claims dating from January 1, 2016 through December 31, 2017. It focused on common risk areas identified by past OIG audits of other hospitals. Of the 100 claims included in the review, the OIG found that Northwest did not comply with Medicare billing requirements for 20 claims, including errors with 13 inpatient claims and 7 outpatient claims. The issues discovered involved inpatient rehabilitation claims not meeting coverage requirements (nine inpatient claims), Part A claims that should have been billed as outpatient or outpatient with observation (two claims), and incorrect coding (two inpatient claims with insufficient documentation for certain DRGs and seven outpatient claims involving improper use of -XS or -XU modifiers). On the basis of the sample, the OIG estimated that the hospital received overpayments of at least $1.2 million during the audit period.
The OIG recommends Northwest refund the Medicare contractor at least $1.2 million, identify and return any similar overpayments, and strengthen controls to ensure full compliance with Medicare requirements. Northwest disagreed with the OIG’s findings for the inpatient rehabilitation claims and the Part A claims involving observation for the same reasons as another hospital, Carolinas, objected to the same findings in a separate review. Northwest stated the OIG reviewer misunderstood the two-midnight rule and applied the wrong standards for medical necessity of inpatient rehabilitation. Northwest also objected to the findings regarding the -XS and -XU modifiers, as it stated that those claims used bypass modifiers appropriately for certain medication administration services occurring during emergency department visits. The OIG, however, maintained that all of its findings and recommendations were correct.
Medicare Outpatient Observation Notice (MOON) Form Delay
On December 3, CMS published an Update on its MOON webpage to announce that although the current MOON form has an expiration date of December 31, 2019, the notice is going through a Paperwork Reduction Act clearance process and will be extended for continued use until an updated notice is published.
Updated Corporate Integrity Agreement Documents
On December 4, the OIG published information on new Corporate Integrity Agreements with the following:
- Louisiana Department of Health, of Baton Rouge, LA
- El Paso Integrated Physicians Group, P.A., and Robert Moreno, M.D., of El Paso, TX
Revisions to Chapter 2 and Addition of Appendix F in the State Operations Manual (SOM) - Community Mental Health Centers (CMHC)
On December 6, CMS published a Memorandum to state survey agency directors regarding revisions to Chapter 2 of the SOM to reflect changes associated with the October 2014 updates of the CMHC Conditions of Participation and other revisions for clarity. These changes include definitions for terms such as CMHC, active treatment plan, comprehensive assessment, partial hospitalization services, and more. The memo also includes information on a new Appendix F that has been added to provide survey instructions and interpretive guidelines associated with the CMHC Conditions of Participation.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state/regional office training coordinators within 30 days of this memorandum.
Comment Request: Medicare Part C and Part D Program Audit and Industry-Wide Part C Timelines Monitoring Project (TMP) Protocols
On December 6, CMS published a Comment Request in the Federal Register regarding an information collection titled, “Medicare Part C and Part D Program Audit and Industry-Wide Part C Timelines Monitoring Project (TMP) Protocols.”
Comments are due by February 4, 2020.
April 2020 HCPCS Quarterly Update Reminder
On December 6, CMS published Medicare Claims Processing Transmittal 4471 regarding a reminder to the contractors that the HCPCS file for the April 2020 quarter will be available in mid-February 2020.
Effective date: April 1, 2020
Implementation date: April 6, 2020
CY 2020 Update for DMEPOS Fee Schedule
On December 6, CMS published Medicare Claims Processing Transmittal 4470 regarding the implementation of the 2020 updates to the DMEPOS fee schedule. This includes new codes, payment updates, changes to payment for therapeutic shoes and diabetic testing supplies, and more.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Cost Reports, Form CMS-2540-10
On December 6, CMS published Provider Reimbursement Manual Transmittal 9 regarding updates to the SNF and SNF Health Care Complex Cost Reports, Form CMS 2540-10 within Chapter 41 of the manual. These updates include clarifications about identifying Medicare utilization for cost report filing, recording demonstration payment adjustments pre and/or post sequestration, and more.
Effective date: Cost reporting periods ending on or after September 30, 2019.
Update to Medicare Claims Processing Manual, Chapters 1, 23, and 35
On December 6, CMS published Medicare Claims Processing Transmittal 4473 regarding revisions to three chapters in the manual to include new sections on global billing and separate technical component/professional component billing, remove obsolete language in places, and update language regarding purchased abstract files.
Effective date: March 9, 2020
Implementation date: March 9, 2020
Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements
On December 6, CMS published One-Time Notification Transmittal 2404, which rescinds and replaces Transmittal 2323, dated July 26, 2019, to remove codes that are not available for 2020 and add in several codes to replace some of the expired codes. The original transmittal was issued regarding HCPCS modifiers that will be used during the testing period for reporting AUC-related HCPCS modifiers on claims with an advanced diagnostic imaging HCPCS code.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Updates to the Coordination of Benefits Agreement Insurance File (COIF) for Use in the National Coordination of Benefits Agreement (COBA) Crossover Process
On December 6, CMS published Medicare Claims Processing Transmittal 4474, which rescinds and replaces Transmittal 4454, dated November 8, 2019, to add a business sub-requirement (11380.1.2) for the Part B shared system to include the new Part B Psychotherapy and Exclusion Indicator within its MCSDT application, which is used to support provider customer service activities. The original transmittal was issued regarding a new Part B psychotherapy claims inclusion option via the COBA crossover process.
Effective date: April 1, 2020
Implementation date: April 6, 2020