This week in Medicare updates—6/16/2021
FY 2022 ICD-10-PCS Codes Available
On June 4, CMS published a Download Link to the 2022 ICD-10-PCS code files on its webpage. These codes will be used for discharges on or after October 1, 2021 through September 30, 2022.
Medicare Quarterly Provider Compliance Newsletter
On June 7, CMS published the Quarterly Provider Compliance Newsletter, which was backdated to April 2021, regarding two recovery auditor findings and one comprehensive error rate testing (CERT) finding. The recovery auditor findings involved medical necessity and documentation requirements for inpatient psychiatric facility services and a finding on the correct number of billable/payable units for single dose vials of drugs/biologicals. The CERT finding involved insufficient documentation for billing continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea.
July 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
On June 8, CMS published Medicare Claims Processing Transmittal 10836, which rescinds and replaces Transmittal 10708, dated April 27, 2021, to update the policy section with additional information from Section 405 of the Consolidated Appropriations Act, 2021. The original transmittal was published regarding the quarterly updates to the ASP and Not Otherwise Classified (NOC) drug files for Medicare Part B drugs.
CMS revised MLN Matters 12244 on the same date to accompany the transmittal.
Effective date: July 1, 2021
Implementation date: July 6, 2021
National Coverage Determination (NCD) Removal
On June 8, CMS published Medicare National Coverage Determinations Transmittal 10838, which rescinds and replaces Transmittal 10797, dated May 20, 2021, to remove the incorrect effective date of October 1, 2021, and to update BR 12254.5 to include reason code 32440. The original transmittal was published regarding the removal of six NCDs from the NCD manual. The transmittal also made a change to NCD 220.6 Positron Emission Tomography (PET) Scans regarding coverage of FDG PET for Infection and Inflammation.
CMS revised MLN Matters 12254 on the same date to accompany the transmittal.
Effective date: January 1, 2021
Implementation date: June 22, 2021; October 4, 2021
Updated List of Excluded Individuals and Entities (LEIE)
On June 8, the OIG updated its LEIE with an updated LEIE database for download and lists of May 2021 exclusions, reinstatements, and profile corrections.
Medicare Payment for COVID-19 Vaccination Administration in the Home
On June 9, CMS updated its COVID-19 Vaccine Shot Payment webpage and published an Infographic regarding a new provision effective June 8 in which Medicare will pay an additional $35 per dose of the COVID-19 vaccine in the home for certain Medicare beneficiaries that have difficulties leaving the home or are hard to reach. The webpage describes who would be eligible for this additional payment, and the infographic provides examples of eligible patients and discusses coding and billing provisions for this payment.
On June 8, CMS added information to its Coding for COVID-19 Vaccines webpage and its Part B Payment for COVID-19 Vaccines and Monoclonal Antibodies webpage instructing providers to report the additional payment for the vaccine by using HCPCS Level II code M0201. On June 9, CMS published a Press Release to announce this payment change.
Replacing Home Health RAPs with a Notice of Admission (NOA) -- Manual Instructions
On June 9, CMS published Medicare Claims Processing Transmittal 10839, which rescinds and replaces Transmittal 10758, dated May 11, 2021, to replace incorrect references to “hospice” with “HHA” in Chapter 10, Section 10.1.10.3. The original transmittal was published regarding updates to chapter 10 of the manual to provide instructions on how to submit NOAs instead of RAPs starting January 1, 2022.
CMS revised MLN Matters 12256 on the same date.
Effective date: January 1, 2022
Implementation date: August 11, 2021
Comment Request: Hospice Facility Cost Report Form
On June 9, CMS published a Comment Request in the Federal Register regarding the submission of an information collection titled “Hospice Facility Cost Report Form” for OMB review.
Comments are due to the OMB desk officer by July 9, 2021.
Updated Provider Self-Disclosure Settlements
On June 9, the OIG published an updated List of Provider Self-Disclosure Settlements with the following organizations:
- On May 5, John F. Kennedy Memorial Hospital and Emanuel Medical Center, of CA, reached a $371,001.45 settlement agreement with the OIG to resolve allegations that they employed an individual they knew or should have known was excluded from participation in federal health care programs.
- On May 7, AIT Laboratories, of TX, reached a $1,541,062.50 settlement agreement with the OIG to resolve allegations that, through its agent, it paid remuneration to 18 home clients in the form of free personnel placed in sober homes as specimen collectors who performed other functions without charge to the sober homes. The OIG also alleged that AIT’s agent forged contracts and orders for laboratory services.
- On May 11, Community Physicians of Indiana reached a $585,016.26 settlement agreement with the OIG to resolve allegations that it submitted claims to federal health care programs for E/M services provided by a physician at assisted living and SNFs for which there was no proof that the services were actually provided.
- On May 13, UnityPoint Clinic - John Deere Road Family Medicine, of IL, reached a $62,988.26 settlement agreement with the OIG to resolve allegations that it submitted claims for services provided by an unlicensed individual.
- On May 27, Diagnostic Imaging and Luminis Health Doctors, of MD, reached a $52,227.24 settlement agreement with the OIG to resolve allegations that it submitted claims for MRIs when they were not medically reasonable or necessary.
Opportunities Exist for CMS and its Medicare Contractors to Strengthen Program Safeguards to Prevent and Detect Improper Payments for Drug Testing Services
On June 9, the OIG published a Review of whether the Medicare contractors’ program safeguards ensure that Medicare claims for drug testing services for beneficiaries with substance use disorder comply with Medicare requirements. The OIG found three weaknesses with program safeguards:
- A lack of clear and consistent requirements or guidance for laboratories to use when determining the number of drug classes to bill for definitive drug testing services
- Inadequate procedures for identifying or limiting the frequency of drug testing services for each beneficiary across all Medicare jurisdictions
- No consistent requirements in LCDs or any procedures for identifying claims for direct-to-definitive drug testing
These weaknesses may lead to improper payments to laboratories, and beneficiaries with substance use disorders may receive medically unnecessary tests.
The OIG recommends CMS determine whether clinical evidence supports a standard for drug testing services and develop an NCD or LCDs with more consistent requirements for these services; clearly indicate in LCDs, LCAs, or other instructions how laboratories should determine the number of drug classes for billing definitive drug testing services; implement a system edit or procedure to limit drug testing services per beneficiary; determine whether a postpayment medical review is necessary for laboratories that have been paid for more than one drug test in a one-week period for the same beneficiary; and consider adding a modifier to claims for definitive drug tests to indicate whether a test was based on results from a presumptive drug test. CMS concurred with the last two recommendations but did not concur with the first three.
Hospice Provider Compliance Audit: Professional Healthcare at Home, LLC
On June 11, the OIG published a Review of whether Professional Healthcare at Home complied with Medicare requirements for hospice services. The OIG found that Professional Healthcare did not comply with Medicare requirements for 21 of the 100 claims reviewed in the sample. Errors involved claims for which the clinical record did not support the beneficiary’s terminal diagnosis and one claim for which there was no documentation that a hospice physician or nurse practitioner had a required face-to-face encounter with the beneficiary. The OIG estimates that Professional healthcare received at least $3.3 million in unallowable Medicare reimbursement for these hospice services.
The OIG recommends Professional Healthcare refund the government for the portion of the $3.3 million in overpayments within the four-year claims reopening period, return any similar overpayments, and strengthen its policies and procedures to ensure that hospice services comply with Medicare requirements. Professional Healthcare disagreed with the OIG’s findings related to the terminal prognosis, stating that the independent medical review contractor erred by relying only on a limited portion of the clinical record to assess the terminal prognosis. After reviewing Professional Healthcare’s comments, the OIG maintained its original findings.
Quarterly Update to the Home Health Grouper
On June 11, CMS published Medicare Claims Processing Transmittal 10834 regarding the October update to the Home Health Grouper software to reflect the annual diagnosis code changes.
CMS published MLN Matters 12303 on the same date to accompany the transmittal.
Effective date: October 1, 2021 - Claims with a From date on or after the effective date
Implementation date: October 4, 2021
Addition of the QW Modifier to HCPCS Codes 0240U, 0241U, 87637
On June 11, CMS published One-Time Notification Transmittal 10827 regarding the addition of modifier QW to HCPCS codes 0240U, 0241U, and 87637. These three codes have received an EUA and are used to report tests for COVID-19. Facilities with valid, current CLIA certificates of waiver or a CLIA certificate for provider-performed microscopy procedures with dates of service on or after October 6, 2020, may report these codes with modifier QW.
CMS published MLN Matters 12318 on the same date to accompany the transmittal.
Effective date: October 6, 2020
Implementation date: July 6, 2021
Provider Enrollment Rebuttal Process - Additional Instructions for Returning Applications and Deactivations
On June 11, CMS published Medicare Program Integrity Transmittal 10828 regarding clarification of MAC procedures for returning enrollment applications and implementing enrollment deactivations.
Effective date: July 12, 2021
Implementation date: July 12, 2021
Quarterly Update for the DMEPOS Competitive Bidding Program (CBP) - October 2021
On June 11, CMS published Medicare Claims Processing Transmittal 10833 regarding the quarterly update to the DME CBP files. These updates implement any necessary changes to HCPCS codes, ZIP codes, and single payment amounts.
CMS published MLN Matters 12298 on the same date to accompany the transmittal.
Effective date: October 1, 2021
Implementation date: October 4, 2021
Updates to Medicare Claims Processing Manual, Chapter 1, Section 10.1 and Chapter 20, Section 10
On June 11, CMS published Medicare Claims Processing Transmittal 10840 regarding updates to the language regarding the DME Jurisdiction List, which will be updated on an as-needed basis and will contain HCPCS codes for which DME MACs have sole or joint jurisdiction.
Effective date: July 12, 2021
Implementation date: July 12, 2021
Implementation of the Hospital Outpatient Department (HOPD) Prior Authorization (PA) Paired Items of Service for the X12 278 PA Transactions
On June 11, CMS published One-Time Notification Transmittal 10842 regarding system processing of HOPD services PA requests from the esMD in the X12 278 transaction format.
Effective date: October 1, 2021
Implementation date: October 4, 2021
NCD 20.9.1 Ventricular Assist Devices (VADs)
On June 11, CMS published National Coverage Determinations Transmittal 10837 and Medicare Claims Processing Transmittal 10837 regarding coverage of VADs under NCD 20.9.1. LVADs will be covered if they are FDA approved for short-term (bridge-to-recovery and bridge-to-transplant) or long-term (destination therapy) mechanical circulatory support for heart failure patients who meet specific clinical criteria.
Effective date: December 1, 2020
Implementation date: July 27, 2021
July 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)
On June 11, CMS published Medicare Claims Processing Transmittal 10825 regarding the July 2021 update to the OPPS. Changes include new CPT codes for the Novavax COVID-19 vaccine (which is still awaiting an EUA or approval from the FDA), new APC assignments for COVID-19 monoclonal antibody administration codes, new language in the manual to reflect a coding change dating back to 2014 pertaining to reporting G0463 for hospital outpatient clinic visits for payment under the OPPS instead of CPT codes 99201-99205 and 99211-99215, and more.
Effective date: July 1, 2021
Implementation date: July 6, 2021
July 2021 Integrated Outpatient Code Editor (I/OCE) Specifications Version 22.1
On June 11, CMS published Medicare Claims Processing Transmittal 10824 regarding the regular quarterly updates to the I/OCE.
Effective date: July 1, 2021
Implementation date: July 6, 2021