Knowledge Base Article

For over a year now, MMP has included updates to CMS transmittals and other CMS news related to acute-care hospitals as a standing article in our Wednesday@One newsletter. Do your eyes sometimes glaze over as you scan titles, numbers, dates, links, etc. or do you hear the adult-speak from the Peanuts cartoons (warnk, warnk, warnk)?  I know I do, so beginning this month, we are presenting this information in a different format. We will present a single straight-forward short description of the topic of the transmittal or other update.  Then if you want to know more, we provide the link to the MLN Article or other applicable document. We hope you find this new format easier to read and a better direction on what you need to know. We welcome your feed-back on our new format.

Updated Part B Drug Pricing Files

Quarterly updates to the ASP Medicare Part B Drug Pricing files.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10187.pdf

New Waived Tests

New waived laboratory tests approved by the FDA for performance in a waived laboratory.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10198.pdf

NPI for CWF Provider Queries

Beginning January 2018, the CWF Provider Queries will only accept NPIs as Valid Provider Numbers.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10098.pdf

Correction to Transfer Payment for MS-DRG 385

CMS is correcting the FISS IPPS Pricer for correct calculation of transfer payments for DRB 385.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10145.pdf

2018 ICD-10-CM POA Exempt Codes Available

The 2018 ICD-10-CM Present on Admission (POA) Exempt Codes are posted on the 2018 ICD-10-CM and GEMs webpage.

Updated Editing of Always Therapy Services

Revised editing of “always therapy” services to require the appropriate therapy modifier in order for the service to be accurately applied to the therapy cap.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10176.pdf

NCD 20.8.4 for Leadless Pacemakers

Effective January 1, 2018, Medicare will cover leadless pacemakers when provided in a CMS-approved study.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10117.pdf

Provider-Based Determination

Beginning November 6, 2017, MACs are required to use a uniform electronic Provider-Based (PB) checklist to perform uniform reviews of provider-based applications.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10095.pdf

HCPCS Codes Used for SNF CB Enforcement

Quarterly (October 1, 2017) update to the list of HCPCS codes that are subject to the Consolidated Billing provision of the SNF Prospective Payment System.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10163.pdf

Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Fiscal Year (FY) 2018

Updates to the Medicare Claims Processing Manual based on the IPF PPS final rule for FY 2018 (October 1, 2017 – September 30, 2018)

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10214.pdf

Quarterly Influenza Virus Vaccine Code Update – January 2018

Quarterly update to flu vaccine codes. Effective January 2018, there is one new influenza virus vaccine code: 90756

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10196.pdf

ICD-10 Coding Revisions to National Coverage Determinations (NCDs)

Periodic updates of claim processing edits based on ICD-10 coding for NCDs.  Watch these carefully as they may affect which ICD-10 codes support medical necessity for the involved services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10184.pdf

ICD-10 GEMS for 2018 Available

The 2018 General Equivalence Mappings (GEMs) are available:

• Diagnosis: 2018 ICD-10-CM and GEMs webpage
• Procedures: 2018 ICD-10-PCS and GEMs webpage

This is the last year that the GEMs will be produced. The 2018 ICD-10-CM Guidelines and Conversion Table will be posted once the Centers for Disease Control and Prevention finalizes them.

Inpatient Prospective Payment System (IPPS) Final Rule

The IPPS final rule was published in the Federal Register on Monday, August 14, 2017. The rule finalizes 2018 payment and policy updates for Medicare hospital admissions.

https://www.gpo.gov/fdsys/pkg/FR-2017-08-14/pdf/2017-16434.pdf

ICD-10-CM Official Guidelines for Coding and Reporting

National Center for Health Statistics (NCHS) published new coding and reporting guidelines for using ICD-10 for fiscal year 2018.

https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf

Credentials of Reviewers

This transmittal instructs Medicare reviewers (MACs, CERT, RACs, and ZPICs) to ensure complex reviews for coverage determinations are performed by Registered Nurses (RNs), therapists or physicians.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R737PI.pdf

Medicare Parts A & B Appeals Process Booklet

A new MLN booklet (June 2017) describes the appeals process, including the latest changes to the appeals process.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedicareAppealsProcess.pdf

Influenza Vaccine Payment Allowances - Annual Update for 2017-2018 Season

Provides the Medicare Part B payment allowances for influenza vaccines for August 1, 2017-July 31, 2018.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10224.pdf

Claim Status Category and Claim Status Codes Update

Updates, as needed, the Claim Status and Claim Status Category Codes for electronically submitted health care claims status requests and responses to explain the status of submitted claim(s).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10132.pdf

Enforcement of the Partial Hospitalization Program (PHP) 20 Hours per Week Billing Requirement - Rescinded

MLN Matters Article SE1307 was rescinded on August 18, 2017.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1607.pdf

Prohibition on Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program – Revision

Revision on August 23, 2017 about system changes to identify the QMB status and exemption from Medicare cost sharing, ways to promote compliance with QMB billing rules, and reminder on Medicare bad debt.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1128.pdf

Proposed Rule- Medicare Program; Cancellation of Advancing Care Coordination Through Episode Payment and Cardiac Rehabilitation Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement Payment Model (CMS-5524-P)

Proposal to cancel the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) incentive payment model and to revise certain aspects of the Comprehensive Care for Joint Replacement (CJR) model.

https://www.federalregister.gov/documents/2017/08/17/2017-17446/medicare-program-cancellation-of-advancing-care-coordination-through-episode-payment-and-cardiac

Provider Error Rate Formula

Instructs Medicare Administrative Contractors (MACs) to include claims denied due to no response to additional documentation requests (ADRs) when calculating the provider error rate.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R738PI.pdf