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August Medicare Transmittals and Other Updates

Published on 

Tuesday, August 25, 2020

 | Billing 
 | Coding 
 | Medicare Coverage 
 | Miscellaneous 
 | Outpatient Services 

MEDICARE TRANSMITTALS – RECURRING UPDATES

 

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2021 Update

  • Article Release Date: August 4, 2020
  • What You Need to Know: This article informs providers about updated ICD-10 conversions and coding updates specific to National Coverage Determinations (NCDs). Change Request 11905 includes coding changes for the following NCDs:
  • NCD 20.4 Implantable Cardiac Defibrillators (ICDs)
  • NCD 50.3 Cochlear Implants
  • NCD 90.2 Next Generation Sequencing (NGS)
  • NCD 220.6.17 Positron Emission Tomography (FDG) for Oncologic Conditions
  • MLN MM11905: https://www.cms.gov/files/document/mm11905.pdf

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2020 Update

Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

  • Article Release Date: August 7, 2020
  • What You Need to Know: This article informs laboratories of changes resulting from the quarterly update to the clinical laboratory fee schedule. With the ongoing Public Health Emergency (PHE) this quarterly update includes changes made due to the COVID-19 pandemic.
  • MLN MM11937: https://www.cms.gov/files/document/mm11937.pdf

Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2021

  • Article Release Date: August 21, 2020
  • What You Need to Know: This article identifies changes required as part of the annual IPF PPS update. Changes are applicable to discharges occurring from October 1, 2020, through September 30, 2021 (FY 2021). The related Change Request (CR) applies to the Medicare Claims Processing Manual (CLM), Chapter 3, Section 190.4.3.
  • MLN 11949: https://www.cms.gov/files/document/mm11949.pdf

 

OTHER MEDICARE TRANSMITTALS

 

New Waived Tests

  • Article Release Date: July 28, 2020
  • What You Need to Know: This article provides information about five new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests that have been approved by the FDA. These tests are marketed immediately after approval so CMS must notify the MACs of the new tests for accurate claims processing. “Note: MACs will not search their files to either retract payment or retroactively pay claims. However, MACs should adjust claims if you bring those claims to their attention.
  • MLN Matters MM11916: https://www.cms.gov/files/document/mm11916.pdf

Update to Osteoporosis Drug Codes Billable on Home Health Claims

  • Article Release Date: August 7, 2020
  • What You Need to Know: Change Request (CR) adds instructions for billing and payment of additional codes for osteoporosis drugs under the home health benefit.
  • MLN MM11846: https://www.cms.gov/files/document/mm11846.pdf

Correction to Editing Update for Vaccine Services

  • Article Release Date: August 7, 2020
  • What You Need to Know: This article informs you that Medicare is changing the Common Working File (CWF) to bypass line-item dates of service for vaccines reported on inpatient Part B claims with Type of Bill (TOB) 12X and 22X when the dates of service (DOS) equal a posted outpatient TOB 73X or 77X service dates, or if present, occurrence span code visit date, regardless of the date of service.
  • MLN MM11867: https://www.cms.gov/files/document/mm11867.pdf

Billing for Home Infusion Therapy Services on or After January 1, 2021

  • Article Release Date: August 7, 2020
  • What You Need to Know: This article provides guidance, for qualified Home Infusion Therapy (HIT) suppliers who bill Medicare Part B MACs, about claims processing systems changes necessary to implement Section 5012(d) of the 21st Century Cures Act. Changes will be effective on or after January 1, 2021.
  • MLN Article: MM11880: https://www.cms.gov/files/document/mm11880.pdf

Telehealth Expansion Benefit Enhancement Under the Pennsylvania Rural Health Model (PARHM) – Implementation

  • Article Release Date: August 10, 2020
  • What You Need to Know: This article provides information about the PARHM and the “Transformation Plans” for participating hospitals. CR 11870 expands the allowable telehealth services for Model-participant hospitals. Without this CR, some hospitals may fail to meet healthcare transformation goals set by the Model. Make sure your billing staffs are aware of these changes.
  • MLN Article MM11870: https://www.cms.gov/files/document/mm11870.pdf

The Intravenous Immune Globulin (IVIG) Demonstration: Demonstration is ending on December 31, 2020

 

REVISED MEDICARE TRANSMITTALS

 

Influenza Vaccine Payment Allowances – Annual Update for 2020-2021 Season

  • Article Release Date: July 10, 2020 – Revised July 31, 2020
  • What You Need to Know: This MLN article was revised to reflect an updated Change Request (CR) 11882 that extended the implementation date to no later than October 1, 2020 and for mass adjustments no later than November 1, 2020.
  • MLN MM11882: https://www.cms.gov/files/document/mm11882.pdf

October 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files – REVISED

  • Article Release Date: July 2, 2020 – Revised August 14, 2020
  • What You Need to Know: Changes made on August 14th were a revised Change Request (CR) release date, transmittal number and web address. All other information remained the same.
  • MLN MM11854: undefined

Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update FY 2021

  • Article Release Date: July 2, 2020 – Revised August 19, 2020
  • What You Need to Know: This article was revised to reflect a revised CR 11859 which “shows that effective for Fiscal Year (FY) 2021, a 5 percent cap will be adopted and applied to all Skilled Nursing Facility providers on any decrease to a provider’s FY 2021 final wage index from that provider’s final wage index of the prior fiscal year (FY 2020).”
  • MLN MM11859: https://www.cms.gov/files/document/MM11859.pdf

 

MEDICARE COVERAGE UPDATES

 

CMS Transmittal 10228 (Change Request 11884): Updates to Chapters 1-8, 10, and 11 to Publication 100-08 (Medicare Program Integrity Manual)

  • Transmittal Release Date: July 27, 2020
  • What You Need to Know: The purpose of Change Request (CR) 11884 is to update all references of Program Safeguard Contractor (PSC) and Zone Program Integrity Contractor (ZPIC) to Unified Program Integrity Contractor (UPIC) within Chapters 1-8, 10, 11, and Exhibits in the Medicare Program Integrity Manual (Publication 100-08).
  • CR11884: https://www.cms.gov/files/document/r10228pi.pdf

CMS Proposes Updates to Coverage Policy for Artificial Hearts and Ventricular Assist Devices (VADs)

CMS announced in an August 12, 2020 Press Release their proposed updates to coverage policies for artificial hearts and VADs, “both of which are used to treat patients with life-threatening advanced heart failure.” The proposed decision memorandum would:

  • Eliminate the coverage with evidence development (CED) requirement for artificial hearts,
  • MACs would become responsible for providing coverage determinations for artificial hearts, and
  • Providers updated coverage criteria for VADs “that better aligns with current medical practice and provides additional flexibility for patients and providers to choose the most appropriate treatments.”

CMS Press Release: https://www.cms.gov/newsroom/press-releases/cms-proposes-updates-coverage-policy-artificial-hearts-and-ventricular-assist-devices-vads

 

OTHER MEDICARE UPDATES

 

July 31, 2020: CMS Releases Inpatient Psychiatric Facility (IPF), Skilled Nursing Facilities (SNF), and Hospices FY 2021 Final Rules

CMS announced in a News Alert that they are “finalizing three Medicare payment rules that further advance our efforts to strengthen the Medicare program by better aligning payments for inpatient psychiatric facilities (IPF), skilled nursing facilities (SNF) and hospices.”   For fact sheets on each final rule, visit:

CY 2021 Physician Fee Schedule (PFS) Proposed Rule with Comment Period

CMS announced the release of this proposed rule in an August 3, 2020 CMS Fact Sheet. A few of the proposals highlighted in the Fact Sheet includes:

  • A proposed CY 2021 PFS conversion factor of $32.26 which is down $3.83 from the CY 2020 PFS conversion factor of $36.09,
  • Proposal to add several services to the Medicare telehealth list on a Category 1 basis,
  • Proposal to create a third temporary category of criteria for adding services to the Medicare telehealth services list. Category 3 describes services added during the PHE for the COVID-19 pandemic that will remain on the list through the calendar year in which the PHE ends. The PHE determination as a result of COVID-19 was most recently renewed on July 23, 2020,
  • Proposal to make permanent following the COVID-19 PHE, the same policy that was finalized under the May 1st COVID-19 IFC, for the duration of the COVID-19 PHE. This proposal would allow nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (PAs) and certified nurse-midwives (CNMs) to supervise the performance of diagnostic tests in addition to physicians, and
  • Proposal to make permanent our Part B policy for maintenance therapy services that we adopted on an interim basis for the PHE in the May 1st COVID-19 IFC that grants a physical therapist (PT) and occupational therapist (OT) the discretion to delegate the performance of maintenance therapy services, as clinically appropriate, to a therapy assistant – a physical therapist assistant (PTA) or an occupational therapy assistant (OTA). 

August 2020 OIG Report: Inadequate Edits and Oversight Caused Medicare to Overpay More Than $267 Million for Hospital Inpatient Claims with Post-Acute-Care Transfers to Home Health Services

The OIG’s objective in performing this audit was to determine whether Medicare properly paid acute-care hospital inpatient claims subject to the transfer policy when hospitals:

  • Did not code the claims as a discharge to home with home health services when the beneficiary resumed home health services within 3 days of discharge,
  • Applied condition code 43 indicating that the home health services were not provided within 3 days of discharge, or
  • Applied condition code 42 indicating that the home health services were not related to the inpatient hospital services.

The OIG audit 150 inpatient claims with dates of service in fiscal years 2016 and 2017 and found that 147 claims were improperly paid with $722,288 in overpayments. Based on the sample the OIG estimated that Medicare improperly paid $267 million during the 2-year period when services should have been paid at a graduated per diem rate.

CMS Announces Initiative to Transform Rural Health

CMS announced new funding opportunities to increase access and improve quality. The Community Health Access and Rural Transformation (CHART) Model “also ties payment to value, increase choice and lowers cost to patients.

Link to August 11, 2020 Press Release: https://www.cms.gov/newsroom/press-releases/trump-administration-announces-initiative-transform-rural-health

Link to CHART Model webpage: https://innovation.cms.gov/innovation-models/chart-model

OIG’s Top Unimplemented Recommendations: Solutions to Reduce Fraud, Waste, and Abuse in the HHS Program

The OIG released their annual publication of this report on August 11th. The top 25 recommendations made are based on audits and evaluations issued through December 31, 2019. Seven of the top twenty-five recommendations are related to Medicare Parts A and B. One of the seven recommendations is that CMS re-evaluate the Inpatient Rehabilitation Facility (IRF) payment system.

The U.S. government’s PaymentAccuracy website “is dedicated to ensuring the American people that its government is addressing…and taking concrete steps on prevention and recovery of improper payments.” According to the Department of Health and Human Services Q4 2019 Payment Scorecard, IRF medical necessity errors resulted in overpayments of $6,740M. Program goals include continuing to educate IRF providers through the Targeted Probe and Educate (TPE) program and approve IRF issues for Recovery Audit Contractor (RAC) review, as appropriate.

Link to PaymentAccuracy website: https://www.paymentaccuracy.gov/about-payment-accuracy/

Article Author:

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.