This week in Medicare updates
Continuation of systematic validation of payment group codes for PPS based on patient assessments
On January 30, CMS released a change request regarding the matter of the Fiscal Intermediary Shared System (FISS) not having access to the assessment databases. This inability to validate the submitted HIPPS code against the associated assessment creates significant payment vulnerability for the Medicare program. This change request continues to implement the FISS changes required to refine the interface between FISS and QIES.
Effective date: July 1, 2015
Implementation date: July 6, 2015
View Transmittal R1459OTN.
Renaming field in the IPPS pricer output
On January 30, CMS released a change request stating the PPS-FLX6- PAYMENT field in the IPPS PRICER output record, created in CR8546, will be renamed to identify this field for the HAC Reduction Amount.
Effective date: July 1, 2015
Implementation date: July 6, 2015
View Transmittal R1457OTN.
View MLN Matters article MM9031.
Corrections to processing service facility information on hospice claims
On January 30, CMS released a change request reporting the standard system is incorrectly replacing the billing facility ZIP code with the service facility location ZIP code, resulting in inaccurate billing provider information and incorrect payments. The hospice benefit does not make payment based on the service facility location, and this instruction will require the standard system to correctly use the billing facility location and not to replace the billing facility location with the service facility location.
Effective date: January 1, 2014
Implementation date: July 6, 2015
View Transmittal R1455OTN.
View MLN Matters article MM9042.
Percutaneous image-guided lumbar decompression (PILD) for lumbar spinal stenosis (LSS)-blinded clinical trial–follow-up
On January 30, CMS released a change request to provide direction as a follow-up to CR8757, Transmittal 2959, dated May 16, 2014. This change request provides additional direction specifically for a new PILD, procedure code when performed in a randomized, blinded clinical trial ONLY, for claims with dates of service on or after January 1, 2015.
Effective date: January 1, 2015
Implementation date: March 2, 2015
View Transmittal R3175CP.
View MLN Matters article MM8954.
Implementation of the Intravenous Immune Globulin (IVIG) Demonstration-Processing for home health service overlap editing
On January 30, CMS released a change request to correct the editing in the standard systems to accurately identify when services to administer IVIG in the home should be covered under the home health benefit and not the demonstration. Change request 8599, dated February 7, 2014, specified the implementation requirements for the IVIG Demonstration. Under this demonstration, demonstration claims are not payable if the beneficiary is receiving home health services under a home health episode of care on the same date of service. In such situations, services related to the administration of IVIG in the home should be provided by the home health provider and covered under the home health payment system. During the testing of CR 8599, a problem was identified in how the date editing was done to identify when beneficiaries enrolled in the demonstration were also receiving home health services.
Effective date: October 1, 2014,retroactive to original demonstration start date
Implementation date: July 6, 2015
View Transmittal R115DEMO.
HCPCS codes subject to and excluded from CLIA edits
On January 30, CMS released a change request to inform contractors about the new HCPCS codes for 2015 that are subject to and excluded from CLIA edits. This recurring update notification applies to Medicare Claims Processing Manual, Chapter 16, section 70.9.
Effective date: January 1, 2015
Implementation date: April 6, 2015
View Transmittal R3182CP.
View MLN Matters article MM9035.
Implementation of new National Uniform Billing Committee (NUBC) Condition Code “53”
On January 30, CMS released a change request implementing Condition Code "53", “Initial placement of a medical device provided as part of a clinical trial or a free sample”, for reporting on the outpatient hospital claim.
Effective date: July 1, 2015 for claims received on or after
Implementation date: July 6, 2015
View Transmittal R3181CP.
View MLN Matters article MM8961.
April 2015 Quarterly Average Sales Price (ASP) Medicare Part B drug pricing files and revisions to prior quarterly pricing files
On January 30, CMS released its quarterly update to the ASP. The ASP methodology is based on quarterly data submitted to CMS by manufacturers. CMS will supply contractors with the ASP and not otherwise classified (NOC) drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the OPPS are incorporated into the OCE through separate instructions that can be located in Chapter 4, section 50 of the Internet Only Manual.
Effective date: April 1, 2015
Implementation date: April 6, 2015
View Transmittal R3180CP.
View MLN Matters article MM9084.
Audio surveillance devices in common areas in intermediate care facilities for individuals with intellectual disabilities (ICF/IID)
On January 30, CMS posted a survey and certification letter regarding the use of audio surveillance devices in the ICF/IID. This practice must be reviewed, approved and monitored by the Specially Constituted Committee (SCC) of the facility as constituted per 42 CFR 483.440(f)(3)(i-iii). If approved by the SCC, written informed consent must be obtained from every affected client or designated guardian prior to the implementation of audio surveillance devices. Audio surveillance devices may be used in common areas within the ICF/IID. Audio surveillance devices may never be used for any reason in areas where there are the highest expectations of privacy such as bathrooms, areas for private visitation, or areas for private phone calls. Audio surveillance devices may not be used as a substitute for or supplement to adequate staffing or supervision protocols. The cost of the audio surveillance devices must be incurred by the facility and not the clients.
View the survey and certification letter.
Revised guidance related to new & revised regulations for hospitals, ASCs, rural health clinics (RHCs) and federally qualified health centers (FQHCs)
On January 30, CMS posted a survey and certification letter regarding updated interpretive guidelines in the following State Operations Manual (SOM) Appendices to reflect recent amendments to the applicable Conditions of Participation (CoPs), Conditions for Coverage (CfCs) and Conditions for Certification: Appendix A – Hospitals, Appendix T - Hospital Swing Beds, Appendix L – ASCs, Appendix G – RHCs and FQHCs. The revised regulations and their associated guidance were effective July 11, 2014, with the exception of the RHC change concerning the requirement to employ at least one nurse practitioner or physician’s assistant; this latter change was effective July 1, 2014.
View the survey and certification letter.
Announcement of the extended temporary moratoria on enrollment of ambulance suppliers and HHAs in designated geographic locations
On February 2, CMS posted a notice in the Federal Register announcing the extension of temporary moratoria on the enrollment of new ambulance suppliers and HHAs in specific locations within designated metropolitan areas in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey to prevent and combat fraud, waste, and abuse.
View the notice in the Federal Register.
FY 2016 Congressional budget justification
On February 2, OIG posted a report regarding its Congressional budget request and justification for FY 2016.
View the report.
Technology assessment related to cognitive outcomes after cardiovascular procedures in older adults
On February 2, CMS posted a new technology assessment related to cognitive outcomes after cardiovascular procedures in older adults.
View the technology assessment.
Medicare Compliance Review of Iowa Methodist Medical Center for 2010 and 2011
On February 3, OIG posted a report detailing its Medicare Compliance Review of Iowa Methodist Medical Center.
View the report.
Review timeliness requirements for prepay review
On February 4, CMS released a change request to change the number of days MACs have to conduct complex review from 60 days to 30 days. Transmittal 566, dated January 23, 2015, is being rescinded and replaced by Transmittal 568 to correct the transmittal number, which was inadvertently duplicated for CR 8443. Additionally, information from CR 8802, section 3.2.3 that was erroneously overwritten has been included. All other information remains the same.
Effective date: March 1, 2015
Implementation date: March 1, 2015
View Transmittal R568PI.
New timeframe for response to Additional Documentation Requests
On February 4, CMS released a change request to update section 3.2.3.2 of Chapter 3 of the Program Integrity Manual to address the new prepayment review timeframe for Additional Documentation Requests (ADRs) submission and to also instruct the Shared Systems Maintainers to produce ADRs to reflect the new change. Transmittal 566 for CR 8583, issued January 7, 2015, is being rescinded and replaced by Transmittal 567, to correct the transmittal number that was erroneously duplicated. All other information remains the same.
Effective date: April 1, 2015
Implementation date: April 6, 2015
View Transmittal R567PI.
Review of Beth Israel Deaconess Medical Center claims that included medical device replacements
On February 5, OIG posted a report Beth Israel Deaconess Medical Center complied with Medicare billing requirements for 3 of the 23 inpatient and outpatient claims reviewed. However, BIDMC did not fully comply with Medicare billing requirements for the remaining 20 claims, resulting in overpayments of approximately $483,000 for calendar years 2010 through 2013.
View the report.
Medicare Compliance Review of Utah Valley Regional Medical Center for 2010 and 2011
On February 5, OIG posted a report detailing a Medicare Compliance Review of Utah Valley Regional Medical Center. Utah Valley Regional Medical Center complied with Medicare billing requirements for 183 of the 232 inpatient and outpatient claims reviewed. However, it did not fully comply with Medicare billing requirements for the remaining 49 claims, resulting in overpayments.
View the report.
Medicare Compliance Review of Missouri Baptist Medical Center for 2011 and 2012
On February 5, OIG posted a report detailing a Medicare Compliance Review of Missouri Baptist Medical Center. This hospital complied with Medicare billing requirements for 207 of the 253 inpatient and outpatient claims reviewed. However, it did not fully comply with Medicare billing requirements for the remaining 46 claims, resulting in overpayments.
View the report.
National coverage determination (NCD) for screening for lung cancer with low dose computed tomography (LDCT)
On February 5, CMS posted decision memorandum and a press release regarding a NCD for screening for lung cancer with LDCT. The coverage is effective immediately. Medicare will now cover lung cancer screening with LDCT once per year for Medicare beneficiaries who meet certain criteria.
View the decision memorandum.
View the press release.
Medicare Compliance Review of University of North Carolina Hospitals for the Period January 1, 2011, Through September 30, 2012
On February 6, OIG posted a report detailing a Medicare Compliance Review of University of North Carolina Hospitals. This hospital complied with Medicare billing requirements for 192 of the 251 inpatient and outpatient claims reviewed. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 59 claims, resulting in net overpayments.
View the report.