This week in Medicare updates—9/15/2021
CMS Announces Support for New Jersey and New York in Response to Hurricane Ida
On September 7, CMS published a Press Release on actions it is taking to support Hurricane Ida recovery efforts in New Jersey and New York. These actions are the same as those taken in Louisiana and Mississippi, and they include steps to ensure dialysis patients can obtain services, waived requirements to help ensure access to certain DMEPOS items, suspension of survey and enforcement activities, and more. Providers should review the press release and CMS’ non-COVID emergency website for more details.
Continuation of and Extension of Timeline for Adjustment of Civil Monetary Penalties for Inflation Final Rule
On September 8, CMS published a Notice in the Federal Register regarding the continuation of the 2016 interim final rule on the adjustment of civil monetary penalties for inflation. In January 2020, CMS previously issued a continuation of the interim final rule, as it said that it inadvertently missed setting a target date for the final rule since the changes to Medicare provisions had been part of a larger, omnibus departmental interim final rule. It therefore needed more time to publish a final rule. In this latest notice, CMS said that due to the resources required to combat the COVID-19 PHE, it needs additional time before publishing a final rule.
Dates: Effective September 3, 2021, Medicare provisions adopted in the interim final rule published on September 6, 2016, continue in effect and the regular timeline for publication of the final rule is extended for an additional year, until September 6, 2022.
Medicare Fee-for-Service Response to the Public Health Emergency on the Coronavirus
On September 8, CMS revised Special Edition MLN Matters 20011, originally dated March 16, 2020, to add more information about SNF waivers, such as noting that CMS is monitoring admissions under section 1812(f) that don’t meet level of care criteria and taking administrative action when appropriate. The original article was issued regarding information on waivers for providers and suppliers during the COVID-19 PHE.
Annual Clotting Factor Furnishing Fee Update 2022
On September 8, CMS published Medicare Claims Processing Transmittal 10973 regarding the annual update to the clotting factor furnishing fee. The fee will be $0.239 per unit in 2022.
CMS published MLN Matters 12420 on the same date to accompany the transmittal.
Effective date: January 1, 2022
Implementation date: January 3, 2022
NCD 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds
On September 8, CMS published Medicare Claims Processing Transmittal 10981 and Medicare National Coverage Determinations Transmittal 10981 regarding implementation for coverage of autologous platelet-rich plasma (PRP) infusions for the treatment of chronic non-healing diabetic wounds. The NCD establishes coverage of this treatment for up to 20 weeks, and additional service beyond that is left to the local MACs’ discretion.
Effective date: April 13, 2021
Implementation date: November 9, 2021 - for MACs; January 3, 2022 - Shared Systems
Claims Processing Instructions for NCD 20.33 - Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation
On September 8, CMS published Medicare Claims Processing Transmittal 10985 and Medicare National Coverage Determinations Transmittal 10985 regarding implementation and claims processing instructions for expanded coverage of TEER of the mitral valve for the treatment of functional mitral regurgitation.
Effective date: January 19, 2021
Implementation date: October 8, 2021
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - October 2021 Update
On September 8, CMS published Medicare Claims Processing Transmittal 10969 regarding the regular quarterly updates to the MPFSDB. Updates include changes to bilateral surgery indicators, diagnostic imaging family indicators, short descriptors, and more.
CMS published MLN Matters 12422 on the same date.
Effective date: October 1, 2021
Implementation date: October 4, 2021
Influenza Vaccine Payment Allowances - Annual Update for 2021-2022 Season
On September 8, CMS published Medicare Claims Processing Transmittal 10983 regarding payment allowances for the influenza vaccine. The specific payment amounts are published on the CMS Seasonal Influenza Vaccines Pricing page.
CMS published MLN Matters 12421 on the same date.
Effective date: August 1, 2021
Implementation date: No later than October 1, 2021
2022 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments
On September 8, CMS published Medicare Claims Processing Transmittal 10971 to provide the files for the automated payments of HPSA bonuses for dates of service in 2022.
CMS published MLN Matters 12367 on the same date.
Effective date: January 1, 2022
Implementation date: January 3, 2022
Instructions for Retrieving the January 2022 Opioid Treatment Program (OTP) Payment Rates Through the CMS Mainframe Telecommunications System
On September 8, CMS published Medicare Claims Processing Transmittal 10979 regarding instructions to the contractors to download and implement the annual OTP update files.
Effective date: January 1, 2022
Implementation date: January 3, 2022
Biden-Harris Administration Expand Vaccination Requirements for Health Care Settings
On September 9, CMS published a Press Release announcing that CMS is expanding emergency regulations requiring vaccinations for staff in hospital, dialysis facility, ambulatory surgical center, and home health settings as a condition for participating in Medicare/Medicaid. CMS is developing an interim final rule with comment period on these requirements, which it said will be issued in October. It is urging any health care workers employed in these facilities who are not vaccinated to begin the process immediately.
Payment Update for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments (PBD)
On September 9, CMS published a Note in MLN Connects stating that CMS will begin reprocessing claims for outpatient clinic visit services provided at excepted off-campus PBDs by November 1, 2021. CMS will be ensuring these visits are paid at the same rate as non-excepted off-campus PBDs under the Physician Fee Schedule. This will affect claims with dates of service between January 1 - December 31, 2019. While CMS will reprocess all affected claims automatically, providers must refund the coinsurance difference to patients or payers who paid the higher coinsurance rates.
Audit of Medicare Payments for Eye Injections of Avastin, Eylea, and Lucentis
On September 10, the OIG published a Review of whether an ophthalmology clinic in Florida complied with Medicare requirements when billing for intravitreal injections of Avastin, Eylea, and Lucentis when billing for other services provided on the same day as the injections. The OIG found that while the clinic complied with requirements for the intravitreal injections, it did not always comply with requirements for billing other services provided on the same day as the intravitreal injections. All 100 claims reviewed by the OIG included at least one service that was not compliant with requirements, as 156 of the 543 services/drugs reviewed on those 100 claims were not separately payable, and 70 services were not reasonable and necessary. The OIG estimates that the clinic received $215,606 in unallowable reimbursement for services provided on the same day as the injections.
The OIG recommends the clinic refund the Medicare contractor for the estimated overpayments. It also recommends the clinic implement policies and procedures to ensure it does not bill for services that are not separately payable from intravitreal injections and to ensure it bills only for services that are reasonable and necessary. Although the clinic said it will appeal certain determinations, it concurred with the remaining recommendations.
Updated List of Excluded Individuals and Entities (LEIE)
On September 10, the OIG updated its LEIE with an updated LEIE database for download and lists of August 2021 exclusions, reinstatements, and profile corrections.
Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
On September 10, CMS published Medicare Claims Processing Transmittal 10988 regarding the quarterly updates to the CLFS.
Effective date: October 1, 2021
Implementation date: October 4, 2021
Mid-Build Exception Audit Recission Announcement
On September 10, CMS published a Notice announcing that it is rescinding the audit determinations for providers notified in January 2021 that their off-campus provider-based departments (PBD) had failed to qualify for the mid-build exception. This exception allowed off-campus PBDs that met certain requirements to continue to be paid under the OPPS rather than under the Physician Fee Schedule, which would pay at 40% of the OPPS rate. The audit determined that 60% of the off-campus PBDs subject to the audit did not meet the exception. However, CMS said that it is rescinding this determination out of an abundance of caution and in response to questions raised by providers regarding the audits. CMS will review each previously failing provider’s audit findings and will allow for providers to submit any additional documentation supporting their eligibility for the exception. Providers who received failing audit determinations are no longer required to report or return overpayments based on those determinations.