This week in Medicare updates—3/17/2021
April 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)
On March 8, CMS published Medicare Claims Processing Transmittal 10666 regarding the quarterly updates to payment, coding, and billing policies in the OPPS. Updates include revised APC assignments for COVID-19 vaccine administration codes, monoclonal antibody codes, status indicator corrections for HCPCS codes G2061 - G20663 and CPT codes 98970 - 98972, and more.
CMS published MLN Matters 12175 on the same date to accompany the transmittal.
Effective date: April 1, 2021
Implementation date: April 5, 2021
April 2021 Integrated Outpatient Code Editor (I/OCE) Specifications Version 22.1
On March 8, CMS published Medicare Claims Processing Transmittal 10667 regarding the regular quarterly updates to the I/OCE.
CMS published MLN Matters 12187 on the same date to accompany the transmittal.
Effective date: April 1, 2021
Implementation date: April 5, 2021
Updated Civil Monetary Penalties and Affirmative Exclusions
On March 8, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions, including:
- On February 2, Doctor’s Inlet Internal Medicine Spine & Pain, of Middleburg, FL, reached a $38,044 settlement agreement with the OIG to resolve allegations that it submitted claims to Medicare for SVT testing in conjunction with claims for urine drug testing when SVT was a non-covered service.
Updated Provider Self-Disclosure Settlements
On March 8, the OIG published an updated List of Provider Self-Disclosure Settlements with the following organizations:
- On February 2, Consulate Health Care of West Altamonte, of FL, reached a $33,388.40 settlement agreement with the OIG after it self-disclosed civil monetary penalties law violations by submitting claims for services by an unlicensed nurse.
- On February 8, Mercy Health Oklahoma Communities, of OK, reached a $10,000 settlement agreement with the OIG after it self-disclosed a civil monetary penalties law violation in which it employed an individual it knew or should have known was excluded from participation in federal health care programs.
- On February 10, University Medical Center of Southern Nevada, of NV, reached a $128,820 settlement agreement with the OIG after it self-disclosed a civil monetary penalties law violation regarding remuneration to a medical group in the form of payments for services that were not included in the personal services contract it had with the medical group.
- On February 23, Virginia Hospital Center Arlington Health System, of VA, reached a $6,050,628 settlement agreement with the OIG after it self-disclosed a civil monetary penalties law violation regarding remuneration to two medical groups in the form of office space, staff, and services rendered under call coverage arrangements.
Peninsula Regional Medical Center: Audit of Medicare Payments for Polysomnography Services
On March 8, the OIG published a Review of whether claims Peninsula Regional Medical Center submitted to Medicare for polysomnography services complied with Medicare requirements. The audit reviewed lines of polysomnography services billed using CPT codes 95810 and 95811. The OIG found that Peninsula did not meet requirements for 10 of the 100 beneficiaries reviewed and 12 of the 169 lines of services for those beneficiaries. The OIG found six lines of service that had incomplete medical record documentation, three lines of service that were incorrectly coded, and one line of service where the billed service was not actually provided. It estimated that, on the basis of the sample, Peninsula received overpayments of at least $66,647 during the audit period for these services.
The OIG recommends Peninsula refund Medicare the estimated $66,647 in overpayments, return any similar overpayments in accordance with the 60-day rule, and implement policies and procedures to ensure that Medicare claims for these services comply with Medicare polysomnography requirements.
Behavioral Health Integration Services
On March 9, CMS revised an MLN Booklet regarding behavioral health integration (BHI) to add updates from the CY 2021 MPFS Final Rule and to add a new HCPCS code G2214 into the coding summary. The 2021 MPFS Final Rule expanded BHI for the psychiatric collaborative care model services to capture shorter increments of time spent with a patient.
Evaluation and Management (E/M) Services Guide
On March 9, CMS revised an MLN Booklet regarding E/M services to add in updates from the 2021 MPFS Final Rule. Changes include updated links and a new “Key Takeaways” section summarizing E/M billing and payment.
Modernization of the Electronic Files Transfer (EFT) Associated with the National Coordination of Benefits Agreement (COBA) Crossover Process
On March 9, CMS published Medicare Claims Processing Transmittal 10638, which rescinds and replaces Transmittal 10559, dated January 20, 2021, to update the dataset names used for Medicare Part A and B COBA claims recoveries, as referenced in 12053.5 and in chapter 28, section 70.6.3 of the manual. The original transmittal was issued regarding new file dataset names that the Virtual Data Centers and associated MACs should use when transmitting and receiving COBA-related files from the Coordination of Benefits & Recovery (COB&R) systems hub.
Effective date: April 5, 2021
Implementation date: April 5, 2021
April 2021 Update to the FY 2021 IPPS
On March 9, CMS published Medicare Claims Processing Transmittal 10669, which rescinds and replaces Transmittal 10572, dated January 15, 2021, to revise business requirement 12062.2, add business requirement 12062.3, and update the background information. The original transmittal was published regarding an update to the IPPS PPS Pricer to allow for up to 10 NDCs to be passed to the IPPS PPS Pricer for payment consideration.
CMS published MLN Matters 12062 on the same date to accompany the transmittal.
Effective date: April 1, 2021
Implementation date: April 5, 2021
Clinical Laboratory Fee Schedule (CLFS) - Medicare Travel Allowance Fees for Collection of Specimens
On March 9, CMS published Medicare Claims Processing Transmittal 10615 regarding payments for travel allowances when billed on a per mileage basis using HCPCS code P9603 and when billed on a flat rate basis using HCPCS code P9604 for CY 2021.
CMS published MLN Matters 12140 on the same date to accompany the transmittal.
Effective date: January 1, 2021
Implementation date: No later than March 19, 2021
Quarterly Update for CLFS and Laboratory Services Subject to Reasonable Charge Payment
On March 9, CMS published Medicare Claims Processing Transmittal 10656 regarding the quarterly update to the CLFS. Updates include the delay in the CLFS data reporting period for clinical diagnostic laboratory tests, six new proprietary laboratory analysis codes, three deleted codes, and more.
CMS published MLN Matters 12178 on the same date to accompany the transmittal.
Effective date: April 1, 2021
Implementation date: April 5, 2021
Comment Request: Disclosures Required of Certain Hospitals and Critical Access Hospitals Regarding Physician Ownership; more
On March 9, CMS published a Comment Request in the Federal Register regarding the following information collections:
- Disclosures Required of Certain Hospitals and Critical Access Hospitals Regarding Physician Ownership
- Evaluation of the CMS Network of Quality Improvement and Innovation Contractors (NQIIC)
Comments are due by May 10.
Primary Care First (PCF) and Serious Illness Patient (SIP) Models: Part 3: IURs and Edits for Non-Sequential Claims
On March 10, CMS published Demonstrations Transmittal 10646, which rescinds and replaces Transmittal 10415, dated October 30, 2020, to add new HCPCS codes to appendices A and B and to change the reason code in business requirement 11911.2. The original transmittal was published in preparation for the implementation of the PCF and SIP Models to address processing certain HCPCS codes under fee-for-service rules for SIP beneficiaries when there is no paid claim line of HCPCS code G2020 and how to reprocess certain previously processed HCPCS codes as flat visit fee claims with demonstration code 96.
Effective date: April 1, 2021
Implementation date: April 5, 2021
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2021 Update
On March 10, CMS published Medicare Claims Processing Transmittal 10631 regarding the quarterly changes to the MPFS payment files. The changes involve changes to the multiple procedure payment reduction indicator for code 0508T, procedure status updates, and a technical correction associated with indirect practice expense allocation for HCPCS codes G2082 and G2083.
CMS published MLN Matters 12155 on the same date to accompany the transmittal.
Effective date: January 1, 2021
Implementation date: April 5, 2021
Comment Request: National Plan and Provider Enumeration System (NPPES) Supplemental Data Collection; more
On March 10, CMS published a Comment Request in the Federal Register regarding the submission of the following information collections for OMB review:
- State Permissions for Enrollment in Qualified Health Plans in the Federally Facilitated Exchange & Non-Exchange Entities
- National Plan and Provider Enumeration System (NPPES) Supplemental Data Collection
Comments are due to the OMB desk officer by April 9, 2021.
Updated List of Excluded Individuals and Entities (LEIE)
On March 10, the OIG updated its LEIE with an updated LEIE database for download and lists of February 2021 exclusions, reinstatements, and profile corrections.
Nursing Home Visitation - COVID-19
On March 10, CMS revised a Memorandum to state survey agency directors regarding guidance for visitation in nursing homes during the COVID-19. Revisions were made to update visitation guidance in accordance with new developments that come from being able to fully vaccinate nursing home residents and staff. Wording has been changed throughout to add in guidance related to visitor/resident vaccination status. Despite evidence that vaccinations can effectively prevent symptomatic SARS-CoV-2 infection in many cases, the CDC and CMS continue to recommend that facilities, residents, and families adhere to core COVID-19 infection prevention policies, such as physical distancing of at least six feet. The guidance also contains information on how to handle indoor visitation during an outbreak, when to limit visitors, whether visitors must be vaccinated as a condition of visitation, and more.
CMS published a Press Release, Fact Sheet, and Statement on the same date.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state/CMS Locations within 30 days of this memorandum.
HCPCS Codes Subject to and Excluded from CLIA Edits
On March 10, CMS published Medicare Claims Processing Transmittal 10613, which rescinds and replaces Transmittal 10564, dated January 20, 2021, to revise bullet 13 in the background section. The original transmittal was issued regarding new HCPCS codes for 2021 that are subject to and excluded from CLIA edits.
CMS revised MLN Matters 12131 on the same date to accompany the transmittal.
Effective date: April 1, 2021
Implementation date: April 5, 2021
HIPAA Electronic Data Interchange (EDI) Front End Updates for July 2021
On March 11, CMS published One-Time Notification Transmittal 10599 regarding the July 2021 Combined Common Edits/Enhancements Module (CCEM) edits for A/B MACs and the CEDI contractor.
Effective date: July 1, 2021
Implementation date: July 6, 2021
Combined Common Edits/Enhancements Modules (CCEM) Code Set Update
On March 11, CMS published Medicare Claims Processing Transmittal 10657 regarding directions to the SSMs to update the tables and/or references files in the CCEM software with the most recent external code sets.
Effective date: July 1, 2021
Implementation date: July 6, 2021
CMS Use of Data on Nursing Home Staffing: Progress and Opportunities To Do More
On March 11, the OIG published a Report regarding how CMS utilizes staffing data as reporting by nursing homes. The OIG reported that while CMS has created a source (Care Compare) for data on nursing home staffing that can be used to help consumers and CMS has implemented a robust process to ensure data reliability, CMS could do more to better use staffing information that nursing homes report. The OIG said CMS could better serve consumers to include data on nurse staff turnover and tenure and it can increase reliability of the non-nurse staff information. The OIG also noted room for CMS improvement in improving effectiveness of state survey agency weekend inspections and in strengthening oversight of staffing in nursing homes.
CMS Announces Final Participants in Emergency Triage, Treat, and Transport (ET3) Model
On March 12, CMS published a Press Release to announce the final list of participants approved to participate in the ET3 Model. The list includes 184 public and private ambulance providers and suppliers across 36 states. CMS is also issuing a Notice of Funding Opportunity for local and state governments to use funding up to $34 million over two years to expand emergency and non-emergency medical triage services in locations participating in the model. The ET3 model tests whether the two components - an integrated medical triage line and the ambulance payment model--can work together to improve quality of care and lower costs by appropriately reducing transports to emergency departments when a different site of service would better serve the patient.
Revisions to the State Operations Manual (SOM), Chapter 2 for Federally Qualified Health Centers
On March 12, CMS published State Operations Provider Certification Transmittal 203 regarding revisions throughout Chapter 2 of the manual based on the MAC transition work on processing certification enrollment actions for FQHCs.
Effective date: March 12, 2021
Implementation date: March 12, 2021
Update to the Manual for Telephone Services, Physician Assistant (PA) Supervision, and Medical Record Documentation for Part B Services
On March 12, CMS published Medicare Benefit Policy Transmittal 10639 and Medicare Claims Processing Transmittal 10639 regarding revisions to the manual to align manual language with policies that had been finalized via the rule-making processes in 2019, 2020, and 2021. This includes policies that had been changed recently regarding broadened types of technology used for communication-technology based services, who can review and verify notes made in the medical record, and current payment policies for PA supervision.
Effective date: January 1, 2019 - for 100-02 and 100-04; January 1, 2020 - for 100-02 only; January 1, 2021 - for 100-02 only
Implementation date: April 12, 2021
April Quarterly Update for the 2021 DMEPOS Fee Schedule
On March 12, CMS published Medicare Claims Processing Transmittal 10681 regarding quarterly updates to the DMEPOS fee schedule. Updates include eight new codes (K1013 - K1020) and three codes removed from category 60 (K1010 - K1012).
Effective date: April 1, 2021
Implementation date: April 5, 2021
Modification to Existing CWF Edits for Osteoporosis Drug Codes Billable on Home Health Claims
On March 12, CMS published One-Time Notification Transmittal 10670, which rescinds and replaces Transmittal 10552, dated January 5, 2021, to update the effective date from date of service to receipt date. The original transmittal was issued regarding modifications to CWF edits 5384 and 7283 for billing and paying additional codes for osteoporosis drugs under the home health benefit.
Effective date: January 1, 2021 - For claims received on or after this date
Implementation date: July 6, 2021
Submission of Condition Codes to the IPPS Pricer to Report Services Provided as Part of an Expanded Access Approval or Emergency Use Authorization
On March 12, CMS published One-Time Notification Transmittal 10597 regarding system changes to pass NUBC condition codes 90 and 91 to the IPPS Pricer when reported on the claim. It also ensures that payer only condition codes ZA-ZZ and provider-submitted condition codes 90 and 91 are passed to downstream systems.
Effective date: July 1, 2021
Implementation date: July 6, 2021
FY 2021 Annual Update to the Medicare Code Editor (MCE) and ICD-10-CM/PCS
On March 12, CMS published Medicare Claims Processing Transmittal 10654, which rescinds and replaces Transmittal 10216, dated July 10, 2020, to remove sensitive/controversial language, add language for new COVID-19 ICD-10 diagnosis and procedure codes, and add requirement 11895.5. The original transmittal was issued regarding updates to the Medicare Code Editor.
Effective date: October 1, 2020 - For diagnosis and procedure code changes included in V38.0 of the MS-DRG Grouper and MCE; January 1, 2021 - For COVID-19 related diagnosis and procedure codes included in V38.1 of the MS-DRG Grouper and MCE
Implementation date: October 5, 2020