A Look Back at 2018

on Wednesday, 02 January 2019. All News Items | Medicare Coverage | Documentation | Billing

Out with the Old, In with the New

Our annual “Look Back” article started with a look back at 2012. This year, in taking a look back to key events in 2018 it brought to mind the saying commonly said on New Year’s Eve, out with the old, and in with the new. For the healthcare community a more apt saying would be out with the old rules, in with new rules and policy changes. This article’s aims are to first highlight “the new” and second equip you with resources needed for compliance with “the new.”  


E/M Service Documentation Provided by Students (Manual Update)

MLN Matters Number: MM10412

CR 10412 revised the Medicare Claims Processing Manual to allow the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work. In this MLN article CMS notes this article is intended for teaching physicians billing MACs and to make sure your billing staff is aware of the changes.

11th - Major Joint Replacement Booklet

Total Knee Procedures (CPT 27447) were removed from the Medicare Inpatient Only List Effective January 1, 2018. CMS also finalized prohibiting RAC “reviews for patient status for TKA procedures performed in the inpatient setting for a period of 2 years to allow time and experience for these procedures under this setting.” However, these procedures remain “fair game” for review for medical necessity of the surgical procedure regardless of patient status.

On January 11th, CMS posted a new Medicare Learning Network (MLN) publication titled Major Joint Replacement (Hip or Knee) Booklet (ICN 909065).  This booklet provides guidance on how to document medical necessity; ensure a complete and accurate medical record; key points for billing codes; and aids to correct billing.

29th – Part A MAC Transition for Jurisdiction J (JJ)

On September 8, 2017 CMS announced that Palmetto, GBA had been awarded the Contract for the A/B MAC Jurisdiction J (JJ) which includes Alabama, Georgia and Tennessee. The Part A transition to Palmetto, GBA on January 29, 2018.

As part of transition, Palmetto GBA consolidated the JM and JJ MAC LCDs.  New for JJ is One Day Stays for Chest Pain LCD (L34551). During a Palmetto GBA transition education session, a Palmetto GBA Medical Director indicated this LCD would be used by the BFCC-QIO (KEPRO) when reviewing short stay claims for chest pain.



9th – Therapy Cap Repealed

Since the Balanced Budget Act of 1997, there has been an annual limitation on the amount Medicare will pay for rehabilitative therapy services for a beneficiary.  This is known as the therapy caps. There has been one therapy cap for outpatient occupational therapy (OT) services and another separate therapy cap for physical therapy (PT) and speech-language pathology (SLP) services combined.  Finally, however, the therapy cap is gone.  The BBA signed into law on February 9, 2018 repealed the therapy cap effective for claims on and after January 1, 2018. You can read more about this in a related MMP article at http://mmplusinc.com/news-articles/item/repeal-of-the-therapy-cap.

13th – New Supplemental Medical Review Contractor (SMRC) Contract Awarded

Prior to February 13, 2018 Strategic Health Solutions was the SMRC. The SMRC performs reviews at the direction of CMS with the aim of lowering the improper payment rates. On February 13, 2018 CMS announced that Noridian Healthcare Solutions, LLC was awarded the new $227 million contract. To learn more about the SMRC you can visit the CMS webpage at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/SMRC.html or the Noridian SMRC webpage at https://www.noridiansmrc.com/.

15th – Implantable Automatic Defibrillator (NCD 20.4) Final Decision Memo

CMS posted a Final Decision Memo on February 15, 2018 for the National Coverage Determination (NCD) for Implantable Automatic Defibrillators (20.4). CMS finalized what they describe as “minimal changes” to the ICD NCD from the 2005 reconsideration. You can read about the “minimal changes” in a related article at http://www.mmplusinc.com/news-articles/item/implantable-cardioverter-defibrillator-decision-memo.

26th – Part B MAC Transition for JJ

The Part B transition to Palmetto GBA occurred on February 26, 2018.

New RAC Complex Review Issue: Cardiac Pacemakers

In February, all Recovery Auditors approved Issue Number 0078, a new complex review for Cardiac Pacemakers.  The issue description states, “Documentation will be reviewed to determine if Cardiac Pacemakers meet Medicare coverage criteria, meet applicable coding guidelines, and/or are medically reasonable and necessary.” Resources for additional information include National Coverage Determination (NCD) 20.8.3 and Local Coverage Articles addressing the billing and coding of pacemakers.  All of the Medicare Administrative Contractors (MACs) released an identical coverage article in 2016 after confusion related to the billing and coding of these services based on the then recently updated NCD.  You can read more about the coverage requirements in a related article at: http://mmplusinc.com/news-articles/item/new-rac-issue-for-cardiac-pacemakers.



1st – Provider Compliance Tips for Bariatric Surgery Fact Sheet

The March 1, 2018 edition of the Medicare Learning Network e-newsletter mlnconnects, included a list of new and revised Provider Compliance Tips Fact Sheets. Included in the Fact Sheets was the new Provider Compliance Tips for Bariatric Surgery Fact Sheet. You can learn more about which Medicare Auditors are reviewing these procedures in a related article at: http://mmplusinc.com/news-articles/item/new-cms-provider-compliance-tips-fact-sheets.

8th – Comprehensive Care for Joint Replacement (CJR) Model FAQs Updated

CMS posted an updated FAQ document on the Comprehensive Care for Joint Replacement (CJR) Model webpage. The document can be found at the bottom of the CJR webpage in the Participant Resources section.  This update reflects several policy changes that were finalized in a December 1, 2017 Final Rule that revised certain CJR model policies.



1st – New Medicare Cards

In an effort to fight medical identity theft, Medicare began mailing new Medicare cards with new numbers in April 2018. A new Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number (HICN) on the new Medicare cards for Medicare transactions like billing, eligibility status, and claim status. You can find more details on the CMS.gov website at https://www.cms.gov/Medicare/New-Medicare-Card/.

10th – Palmetto GBA and Observation Services

“Observation care services are covered only when provided by the order of a physician or another individual authorized by state licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient tests. These services must be deemed reasonable and necessary to be covered by Medicare. Please share with appropriate staff.”

Palmetto GBA posted the above comment in their April 10, 2018 Daily Newsletter. This reminder also included an article about Observation Care on the Palmetto GBA website.

It is important to note that for hospitals in Jurisdiction J, in addition to a new Chest Pain LCD, Palmetto has an Outpatient Observation Bed/Room Services (L34552) Local Coverage Determination (LCD).

24th – Fiscal Year (FY) 2019 IPPS Proposed Rule (CMS-1694-P) Issued

CMS projected that total Medicare spending on inpatient hospital services, including capita, will increase by about $4 billion in FY 2019 which is a significant increase from their projection of $3.1 billion in FY 2018.

ICD-10-CM Coding for Social Determinants of Health

In April the American Hospital Association (AHA) released a Fact Sheet which indicated “numerous studies have demonstrated a link between economic status, social factors and physical environment as key influencers in health outcomes.” To that end, the AHA working with the AHA Coding Clinic and in the First Quarter 2018 Coding Clinic advice was published to allow “reporting codes from categories Z55-Z65, based on information documented by all clinicians involved in the care of the patient.” This change was effective February 18, 2018.

Link to AHA Fact Sheet: https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdf



15th – CMS Unveils Enhanced “Drug Dashboards” to Increase Transparency on Drug Prices

For the first time, the dashboards include year-over-year information on drug pricing and highlight which manufacturers have been increasing their prices.

Link to CMS Press Release: https://www.cms.gov/newsroom/press-releases/cms-unveils-enhanced-drug-dashboards-increase-transparency-drug-prices

MLN Fact Sheet: Complying with Medicare Signature Requirements

This fact sheet describes common Medicare Comprehensive Error Rate Testing (CERT) Program errors related to signature requirements. It helps providers and their clinical and office staff understand the documentation needed to support a claim submitted to Medicare for medical services and supplies.

Link to Fact Sheet: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Signature_Requirements_Fact_Sheet_ICN905364.pdf



18th – Resolution Tips for Overlapping Claims

This article posted to the Palmetto GBA website is intended to assist providers that experience claim rejections for overlapping dates of service.  You can read more about this in a related MMP article at: http://www.mmplusinc.com/news-articles/item/overlapping-claims.

MLN Matters SE18006: New Medicare Beneficiary Identifier (MBI) Get It, Use It

CMS released this special MLN article providing ways that staff can get a Medicare beneficiary’s MBI that is on the new Medicare cards that are being mailed in phases by geographic location. This article has since been revised December 10, 2018 to update the language regarding when MACs can return an MBI through the MBI look up tool.

Link to Special MLN Article: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18006.pdf



25th – CY 2019 OPPS Proposed Rule Released

Proposed Changes to the Inpatient Only (IPO) List and Ambulatory Surgery Center (ASC) Covered Surgical Procedures for 2019

The good news for hospitals for the coming year was there was no proposal to remove partial or total hip arthroplasty from the IPO list and no major joint procedure list (TKA, PHA, and THA) was proposed for addition to the ASC procedure list. You can read about what was proposed in a related MMP article at: http://mmplusinc.com/news-articles/item/proposed-changes-to-the-inpatient-only-list-asc-covered-surgical-procedures-for-2019.

26th – CMS’ Beneficiary Notices Initiative (BNI) Webpage Update

Providers and the Medicare beneficiary have certain rights and protections related to financial liability and appeals under the Medicare Fee-for-Service (FFS) and Medicare Advantage (MA) Programs. On July 26th CMS updated their BNI home page to include a user friendly table detailing each notice, type of notice, provider type, purpose for the notice and links to take you to the notice. A few examples of the notices found on this webpage include the Advanced Beneficiary Notice of Non-Coverage (ABN), Hospital Issues Notices of Non-Coverage (HINNs), and the Medicare Outpatient Observation Notice (MOON).

30th – CMS’ Medicare Fee for Service Recovery Audit Program Webpage Update

CMS updated their RAC Program information to a home page with a table providing links to each of the RACs website, their email address and 1-800 phone number. Additional pages include a new Proposed RAC Topics, new Approved RAC Topics webpage and a Resources Page.

Link to CMS RAC website information: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Resources.html



2nd – FY 2019 IPPS Final Rule Released

The following table highlights key policy changes finalized and links to related MMP, Inc. articles.

Finalized Policy ChangesLink to Related MMP, Inc. Article
Inpatient Status Order Requirements Changed http://mmplusinc.com/news-articles/item/inpatient-status-orders-requirements-changed
2019 IPPS Final Rule Payment Changes, Burden Reduction & Price Transparency http://mmplusinc.com/news-articles/item/2019-ipps-final-rule-payment-changes-burden-reduction-and-price-transparency
Requirements for Hospitals to Post Standardized Prices http://mmplusinc.com/news-articles/item/faq-posting-standardized-prices
MS-DRG Changes http://mmplusinc.com/news-articles/item/ipps-fy-2019-final-rule-ms-drg-updates
Post-Acute Care Transfer Policy Changes http://mmplusinc.com/news-articles/item/post-acute-care-transfer-policy-issues
ICD-10-PCS Codes Re-designated as Non-O.R. or O.R. Procedures http://mmplusinc.com/news-articles/item/icd-10-pcs-codes-re-designated-as-o-r-or-non-o-r-2019-ipps-final-rule
Quality Program Policy Changes http://mmplusinc.com/news-articles/item/ipps-fy-2019-final-rule-part-3-quality-programs

31st- Comprehensive Care for Joint Replacement (CJR) Model: 1st Annual Report to Congress

The 1st Annual Report examined Lower Extremity Joint Replacement Episodes (LEJR) on or after April 1, 2016 and ended December 31, 2016. The Lewin Group with partners was contracted by CMS to evaluate the impact of the model. “CJR participant hospitals were able to reduce payments through changes in utilization while maintaining quality of care. At the same time, we found no indication that CJR participant hospitals selected healthier patients to achieve these results.”

The entire report, report appendices and a two page high level “Findings at a Glance” summary can be accessed on the CMS CJR webpage at https://innovation.cms.gov/initiatives/cjr.



26th – FY 2018 Readmission Penalties

Will you be subject to a Readmission Penalty in FY 2019? Kaiser Health News (KHN) is a nonprofit national health policy news service and on September 26th, Jordan Rau of KHN released the article Medicare Eases Readmission Penalties Against Safety Net Hospitals. This article includes links to review penalties by Hospital or State. The entire article can be accessed at: https://khn.org/news/medicare-eases-readmissions-penalties-against-safety-net-hospitals/.



3rd- 2019 IPPS Final Rule Correction Published in Federal Register

One specific correction was related to a new drug approved for New Technology and Add-On Payment for FY 2019, VABOMERE™. CMS indicated that “On page 41311, we made a typographical error in describing which National Drug Code (NDC) will be used to identify cases involving VABOMERE™ that are eligible for new technology add-on payments in FY 2019. Specifically, we are correcting the NDC code of 65293–0009–01, which erroneously was missing an extra digit. In addition, we were made aware after the final rule that NDC 70842–0120–01 can also be used to identify cases of VABOMERETM. Therefore, cases involving the use of VABOMERE™ that are eligible for new technology add-on payments in FY 2019 will be identified with either of the following NDCs: 65293–0009–01 and 70842–0120–01.”

You can read more about VABOMERE™ in a related article at: http://mmplusinc.com/news-articles/item/alert-oct-3-2018.

3rd – MLN Matters MM10901: Local Coverage Determinations (LCDs)

This MLN article is intended for physicians, providers, and suppliers billing MACs for services provided to Medicare beneficiaries. Per the article, “Change Request (CR) 10901 notifies MACs that, in accordance with Section 4009 of H.R. 34-21st Century Cures Act (Public Law No: 114-255), the Centers for Medicare & Medicaid Services (CMS) is updating the Medicare Program Integrity Manual with detailed changes to the Local Coverage Determination (LCD) process. You should ensure that your staffs are aware of these changes.”

You can read more about changes being made in a related article at: http://mmplusinc.com/news-articles/item/cms-revises-lcd-process.

12th – 2019 Medicare Parts A & B Premiums and Deductibles

A CMS Fact Sheet released the 2019 premiums and deductibles. The standard monthly premium for Medicare Part B enrollees will be $135.50 for 2019. The annual deductible for Medicare Part B beneficiaries is $185 in 2019. The Medicare Part A inpatient deductible that beneficiaries will pay when admitted to the hospital is $1,364 in 2019.

Link to CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/2019-medicare-parts-b-premiums-and-deductibles



2nd – OPPS Final Rule for Calendar Year 2019 Released

CMS posted a Fact Sheet indicating that the CY 2019 OPPS Rule (CMS-1695-FC) had been finalized. The following table highlights key Policy Changes finalized and links to related MMP, Inc. articles.  

Finalized Policy ChangesLink to Related MMP, Inc. Article
Comprehensive APCs, Composite APCs, Drug & Biological Payments, and Device-Intensive Procedures http://mmplusinc.com/news-articles/item/the-2019-opps-final-rule
Inpatient Only List & ASC Covered Surgical Procedures http://mmplusinc.com/news-articles/item/finalized-changes-to-the-inpatient-only-list-asc-covered-surgical-procedures-for-2019
Provider-Based Departments http://mmplusinc.com/news-articles/item/final-2019-rule-changes-for-provider-based-departments


15th - Medicare Physician Fee Schedule Final Rule Published

Specific issues in this Final Rule that will impact hospital providers includes the following:

  • Off-Campus Provider Based Departments
  • Therapy Services,
  • Laboratory Services, and Appropriate Use Criteria for Advanced Imaging.

Link to related article: http://mmplusinc.com/news-articles/item/2019-mpfs-final-rules-affecting-hospitals

21st – NCD 20.4 Implantable Cardiac Defibrillators (ICDs) Updated

CMS published Change Request (CR) 10865 related to implementing changes published in the ICD Final Decision Memo on February 15th. This information can also be found in related MLN Matters MM10865 at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10865.pdf.



3rd – Hospital Value-Based Purchasing Program Results for FY 2019

The law requires CMS to reduce a portion of the base operating Diagnosis-Related Group (DRG) payment amounts otherwise applicable to a participating hospital for each Medicare Fee-for-Service discharge by two percent (2%). The estimated sum total of these reductions is redistributed to participating hospitals based on their performance. CMS estimates the total amount available for FY 2019 is approximately $1.9 billion. In a December 3rd, 2018 Fact Sheet, CMS announced they had posted the adjustment factor for each participating hospital in Table 16B for FY 2019.

13th – New Medicare Care: MAC Look-Up Tool Updated

In the December MLNConnects newsletter CMS announced that you’re MACs “secure portal Medicare Beneficiary Identified (MBI) look-up tool now returns the MBI even if the new Medicare has not been mailed. If you do not already have access, access, sign up for your MAC’s portal to use the tool. For more information on the transition to the MBI:

You can also ask your patients to call 1-800-MEDICARE to get a new card if they need one. To ensure your Medicare patients continue to get care, you can use either the Health Insurance Claim Number or the MBI for all Medicare transactions through December 31, 2019.”

Hospital Price Transparency

In early December CMS released the document Additional Frequently Asked Questions Regarding Requirements for Hospitals to Make Public a List of Their Standard Charges via the Internet. Additional information about this requirement can be found in a related MMP FAQ at: http://mmplusinc.com/news-articles/item/2019-ipps-final-rule-requirement-to-post-standardized-prices.


Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc.  Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. 

In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Risk Assessment (CRA) Tool. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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