Knowledge Base Category -
Ambulance Inflation Factor for CY 2018 and Productivity Adjustment
The Calendar Year (CY) 2018 Ambulance Inflation Factor (AIF) for determining the payment limit for ambulance services is 1.1 percent.
Correction to Prevent Payment on Inpatient Information Only Claims for Beneficiaries Enrolled in Medicare Advantage Plans
Sets system edits to zero out payment on inpatient information only claims billed with condition codes 04 and 30 for Investigational Device Exemption (IDE) Studies and Clinical Studies Approved Under Coverage with Evidence Development (CED).
New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set- Aside Arrangements (NFMSAs) - RESCINDED
Clarifying Signature Requirements
Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies. Claim denials shall be limited to those instances in which signatures that are required by Medicare policies are flawed or missing.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R751PI.pdf
Clinical Laboratory Improvement Amendments of 1988 (CLIA); Fecal Occult Blood (FOB) Testing
Clarifies CLIA regulations that the waived test categorization applies only to non- automated fecal occult blood tests.
https://www.gpo.gov/fdsys/pkg/FR-2017-10-20/pdf/2017-22813.pdf
Calculating Interim Rates for Graduate Medical Education (GME) Payments to New Teaching Hospitals – REVISED
Re-issued to revise several policy statements and to address how to handle certain impacted claims.
New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set-Aside Arrangements (NFMSAs) – REPLACED
Removes provider education requirements from original transmittal.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1954OTN.pdf
Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs Final Rule
Revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2018.
https://www.gpo.gov/fdsys/pkg/FR-2017-11-13/pdf/2017-23932.pdf
Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018
Addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies to update payment systems to reflect changes in medical practice and the relative value of services, as well as changes in the statute. In addition, this final rule includes policies necessary to begin offering the expanded Medicare Diabetes Prevention Program model.
https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953.pdf
Implementation of the Award for the Jurisdiction Part A and Part B Medicare Administrative Contractor (JJ A/B MAC)
Announces CMS has awarded the JJ A/B MAC contract for the administration of the Part A and Part B Medicare fee-for-service claims in the states of Alabama (AL), Georgia (GA) and Tennessee (TN) to Palmetto GBA LLC.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1960OTN.pdf
Update to Pub 100-04, Chapter -18 Preventive and Screening Services -Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)
Adds ICD-10 diagnosis codes: F17.210 (Nicotine dependence, cigarettes, uncomplicated), F17.211 (Nicotine dependence, cigarettes, in remission), F17.213 (Nicotine dependence, cigarettes, with withdrawal), F17.218 (Nicotine dependence, cigarettes, with other nicotine-induced disorders), or F17.219 (Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders), for LDCT coverage.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3901CP.pdf
Billing Requirements for Ophthalmic Bevacizumab
Clarifies HCPCS code for billing ophthalmic bevacizumab.
Notification of the 2018 Dollar Amount in Controversy Required to Sustain Appeal Rights for an Administrative Law Judge (ALJ) Hearing or Federal District Court Review
ALJ hearing requests amount for 2018 will remain at $160. Federal District Court appeals amount will increase to $1,600 for 2018.
Accepting Payment from Patients with a Medicare Set-Aside Arrangement
Explains what a MSA is and explains why it is appropriate to accept payment from a patient that has a funded MSA.
CMS Hospital Value-Based Purchasing Program Results for Fiscal Year 2018
Fact Sheet describing VBP program and updates. Estimates the total amount available for value-based incentive payments for FY 2018 discharges will be approximately $1.9 billion.
Additional Appeals Settlement Option
CMS will make available an additional settlement option for providers and suppliers (appellants) with appeals pending at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council (the Council) at the Departmental Appeals Board.
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
NCD coding changes the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
CMS Posts RAC Review Topics
CMS has begun to post a list of review topics that have been proposed, but not yet approved, for RACs to review. These topics will be listed, on a monthly basis, on the Provider Resources page.
Partial Settlement of 2-Midnight Policy Court Cases
Provides instructions to Medicare Administrative Contractors (MACs) on how to ensure hospitals receive additional payments due to a partial settlement agreement regarding the 0.2 percent downward adjustment beginning in Fiscal Year ("FY") 2014.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1969OTN.pdf
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).
Annual Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
Provides the 2018 annual update to the list of Healthcare Common Procedure Coding System (HCPCS) codes used by Medicare systems to enforce consolidated billing of home health services.
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP), and PC Print Update
Updates the Remittance Advice Remark Codes (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs Medicare Shared System Maintainers (SSMs) to update Medicare Remit Easy Print (MREP) and PC Print.
Claim Status Category Codes and Claim Status Codes Update
MAC and shared systems changes will be made as necessary as part of a routine release to reflect applicable changes such as retirement of previously used codes or newly created codes.
Therapy Cap Values for Calendar Year (CY) 2018
For physical therapy and speech-language pathology combined, the CY 2018 cap is $2,010. For occupational therapy, the CY 2018 cap is $2,010.
New Positron Emission Tomography (PET) Radiopharmaceutical/Tracer Unclassified Codes
CMS has created two new PET radiopharmaceutical unclassified tracer codes that can be used temporarily pending the creation/approval/implementation of permanent CPT codes that would later specifically define their function: A9597 - Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified; A9598 – Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified.
2018 Medicare Parts A & B Premiums and Deductibles
On November 17, 2017, the Centers for Medicare & Medicaid Services (CMS) released the 2018 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs. The standard monthly premium for Medicare Part B enrollees will be $134 for 2018, the same amount as in 2017. The annual deductible for all Medicare Part B beneficiaries will be $183 in 2018, the same annual deductible in 2017. The Medicare Part A annual inpatient hospital deductible that beneficiaries pay when admitted to the hospital will be $1,340 per benefit period in 2018, an increase of $24 from $1,316 in 2017.
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-17.html
Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
Provides the quarterly update of HCPCS codes used for HH consolidated billing effective April 1, 2018.
Finally fall weather has arrived in the South. The days are not too hot or too cold, so it is the perfect season to spend some time outdoors. Yesterday my dog and I went walking through the woods. Many of the paths had obstacles such as fallen trees or low hanging branches, so we would have to adjust and try a different route. This is also the time of year to get ready to adjust your paths with Medicare due to policy changes finalized in the 2018 Outpatient Prospective Payment System (OPPS) Final Rule that will become effective January 1, 2018.
Two of our Wednesday@One articles last week addressed finalized policies from the 2018 OPPS Final Rule – changes to the inpatient only list and payment reduction for separately payable drugs purchased through the 340B program. This week we will examine some of the other significant policy changes from the 2018 OPPS final rule that will require some provider adjustments.
Drug Administration
Over the past several years, CMS has taken numerous actions to move the OPPS more toward an actual prospective payment system as the name indicates. To this end, “the OPPS packages payments for multiple interrelated items and services into a single payment to create incentives for hospitals to furnish services most efficiently and to manage their resources with maximum flexibility.” Specifically, over the past few years CMS has created and expanded comprehensive APCs which bundle payment for all adjunctive services into the payment for the primary service, packaged add-on codes, and conditionally packaged payment of ancillary services with a geometric mean cost of $100 or less.
Drug administration services have, up until this year, escaped the packaging concept as CMS examined various alternative payment policies for drug administration, including the associated drug administration add-on codes. Finally, in 2018 CMS takes a baby step toward packaging of some drug administrative services. They are conditionally packaging payment for some Level 1 and Level 2 drug administration services with a status indicator (SI) of “Q1” (see table below). Vaccine administration codes for preventive services (influenza, pneumococcal, and hepatitis B) and add-on drug administration codes, which still have an SI of “S,” are not packaged and will continue to be paid separately. Vaccine admin codes 90471 and 90473, that are for administration of vaccines other than preventive services, are conditionally packaged. Since the Level 1 and 2 drug admin codes are conditionally packaged, they will be separately payable when not billed on the same claim as a HCPCS code with status indicator “S”, “T”, or “V”. The main impact from this drug admin packaging for hospitals will be for CPT code 96372 (therapeutic SQ/IM injection), and CPT codes 96401 and 96402 (chemotherapy SQ/IM injection codes).
As usual for packaged codes, CMS reminds hospitals that they are expected to report all HCPCS codes that describe the services provided, regardless of whether or not those services are separately paid or their payment is packaged. Although CMS did not package payment for add-on drug administration codes for 2018, they discussed the comments received and may propose more drug administration packaging in future years.
Lab Date of Service Policy
Probably the most difficult revised policy to explain and understand is the lab date of service policy. Laboratory date of service (DOS) rules start simple:
- The DOS for clinical diagnostic laboratory services generally is the date the specimen is collected.
- For archived lab specimens that are stored for more than 30 days before testing, the DOS is the date the specimen was obtained from storage.
Now this is where it starts getting complicated with what is known as the 14-day rule.
- The DOS is the date the test was performed (instead of the date of collection) if the following conditions are met:
- The test is ordered by the patient’s physician at least 14 days following the date of the patient’s discharge from the hospital;
- The specimen was collected while the patient was undergoing a hospital surgical procedure;
- It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted;
- The results of the test do not guide treatment provided during the hospital stay; and
- The test was reasonable and medically necessary for the treatment of an illness.
- Another 14-day rule applies to chemotherapy sensitive tests performed on live tissue under the same conditions as described above with only slight variation to the first condition:
- The decision regarding the specific chemotherapeutic agents to test is made at least 14 days after discharge;
Both of these 14-day rules apply to hospital inpatients and outpatients and the key point is that the test is ordered at least 14 days after discharge. These DOS requirements determine whether the hospital bills Medicare for a clinical diagnostic laboratory test (CDLT) or whether the laboratory performing the test bills Medicare directly. When the 14-day rule applies, laboratory tests are not bundled into the hospital stay, but are instead paid separately under Medicare Part B to the testing laboratory.
Stakeholders expressed concerns about the current DOS policy because it requires hospitals to bill for tests they did not perform and that may have no relationship to or bearing on treatment received by the patient while in the hospital and it creates billing difficulties for the hospital. CMS agreed with these concerns and modified the date of service rule for hospital outpatients for molecular pathology tests and advanced diagnostic laboratory tests (ADLTs) that are not packaged under OPPS. These types of lab test have a Status Indicator of “A” on Addendum B.
The new rule states that in the case of a molecular pathology test or an ADLT, the DOS of the test must be the date the test was performed only if—
- The test was performed following a hospital outpatient’s discharge from the hospital outpatient department;
- The specimen was collected from a hospital outpatient during an encounter (as both are defined in 42 CFR 410.2);
- It was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter;
- The results of the test do not guide treatment provided during the hospital outpatient encounter; and
- The test was reasonable and medically necessary for the treatment of an illness.
This new exception to the laboratory DOS policy does not apply to ADLT or molecular pathology tests when performed on a specimen collected from a hospital inpatient.
This new laboratory DOS policy will enable laboratories performing ADLTs and molecular pathology tests excluded from the OPPS packaging policy to bill Medicare directly for those tests, instead of requiring them to seek payment from the hospital outpatient department. In fact, for molecular pathology tests and ADLTs meeting the above requirements, the DOS must be the date the test was performed and the test must be billed by the performing laboratory. Hospital laboratories cannot bill for these tests unless they perform them.
Supervision of OP Therapeutic Services
In the 2009 OPPS final rule, CMS clarified that direct supervision is required for hospital outpatient therapeutic services covered and paid by Medicare that are furnished in hospitals as well as in provider-based departments (PBDs) of hospitals. They further clarified in the 2010 rule that this supervision requirement also applies to Critical Access Hospitals (CAHs). Beginning in March 2010 and extending through December 31, 2016, CMS or Congress implemented and extended nonenforcement of this supervision requirement for CAHs and small rural hospitals having 100 or fewer beds. Due to concerns that some small rural hospitals and CAHs have insufficient staff available to furnish direct supervision, CMS is reinstating the non-enforcement instruction for CYs 2018 and 2019. This nonenforcement again applies to CAHs and small rural hospitals with 100 or fewer beds to give them more time to comply with the supervision requirements for outpatient therapeutic services and to submit specific services to be evaluated by the HOP Panel for a recommended change in the supervision level.
Other 2018 OPPS Updates
- Skin Substitutes – CMS will continue to assign skin substitutes as low cost or high cost based on their unit or per day cost. In addition, a skin substitute product that does not meet high cost criteria for CY 2018, but was assigned to the high cost group for CY 2017, will remain assigned to the high cost group for CY 2018 in order to maintain payment consistency.
- Comprehensive APCs – There are no new C-APCs for 2018.
- Brachytherapy – CMS decided not to finalize a proposed policy to establish an edit that requires a brachytherapy treatment code when a brachytherapy insertion code is billed. They are deleting Composite APC 8001 (LDR Prostate Brachytherapy Composite) and assigning HCPCS code 55875 to existing C-APC 5627 (Level 7 Radiation Therapy).
- SRS Treatment – CMS is deleting modifier CP for services that are adjunctive to the primary stereotactic radiosurgery services (SRS) treatment described by HCPCS codes 77371 and 77372, but reported on a different claim. They will continue to make separate payment for the 10 planning and preparation codes adjunctive to the delivery of SRS treatments when furnished within one month of treatment.
- Bone Marrow Aspiration and Biopsy – CMS is deleting the add-on code G0364 and creating a new code (38222) to describe a diagnostic bone marrow with both aspiration and biopsy. The new code is assigned a status indicator of “J1” to the same APC as the codes for a bone marrow aspiration or a bone marrow biopsy performed separately.
This is not of course all of the policy changes from the 2018 OPPS final rule, but maybe the ones you should consider first and make process changes if necessary. The path to billing for Medicare services continually requires adjustments.
Debbie Rubio
Calculating Interim Rates for Graduate Medical Education (GME) Payments to New Teaching Hospitals
Provides instructions to the MACS on calculating interim rates for Graduate Medical Education (GME) payments to new teaching hospitals.
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2017 Update
Recurring quarterly update to HCPCS code set – created new modifier ZC for use with biosimilars manufactured by Merck/Samsung Bioepis, such as Infliximab.
Updates to Medicare’s Cost Report Worksheet S-10 to Capture Uncompensated Care Data
Provides additional guidance to 1886(d) hospitals to ensure appropriate reporting of uncompensated care costs and to achieve proper Medicare reimbursement. Summarizes revisions and clarifications to the instructions for the Worksheet S-10 of the Medicare cost report.
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edits, Version 24.0, Effective January 1, 2018
Recurring quarterly updates of CCI edits.
Accepting Payment from Patients with a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA), a Liability Insurance Medicare Set-Aside Arrangement (LMSA), or a No-Fault Insurance Medicare Set-Aside Arrangement (NFMSA) - RESCINDED
Rescinded October 3, 2017
Implementing the Remittance Advice Messaging for the 20 Hour Weekly Minimum for Partial Hospitalization Program Services – REISSUE
Re-issued on October 3, 2017, to confirm that its content remains valid even though Special Edition Article SE1607 was rescinded. Message on remittance reminding providers that PHP patients require a minimum of 20 hours of PHP services per week, in accordance with the plan of care.
Medicare Appeals; Adjustment to the Amount in Controversy (AIC) Threshold Amounts for Calendar Year 2018
Federal Register Notice – The calendar year 2018 AIC threshold amounts are $160 for ALJ hearings and $1,600 for judicial review.
https://www.gpo.gov/fdsys/pkg/FR-2017-09-29/pdf/2017-20883.pdf
January 2018 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Quarterly update to drug pricing. OPPS hospitals are paid ASP + 6% for separately paid drugs (both pass-through and non-pass-through drugs).
Transition to New Medicare Numbers and Cards
Factsheet telling the why, when, and how to be ready for the new cards.
Clarification Regarding the Use of Control Materials as Calibrators to Determine Test Cut-off Values (Laboratories)
Memorandum to State Survey Agency Directors clarifying information concerning laboratory controls and calibration materials.
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2018
Quarterly updates to the national coverage policies for certain laboratory tests. There is a link within the article to a spreadsheet of all the changes – deletions and additions.
Clinical Laboratory Fee Schedule Not Otherwise Classified, Not Otherwise Specified or Unlisted Service or Procedure Code Data Collection
Instructs providers to include the laboratory test name or short description in Field 19 when billing an unlisted laboratory test code on a 1500 claim form. Also, laboratory “reporting entities” must report private payor payment rates and volumes for unique tests reported with an unlisted code.
2018 Medicare Electronic Health Record (EHR) Incentive Program Payment Adjustment Fact Sheet for Hospitals
Fact sheet on the EHR payment adjustments for eligible hospitals.
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-10-10.html
Notice of New Interest Rate for Medicare Overpayments and Underpayments -1st Qtr. Notification for FY 2018
The certified interest rate effective October 18, 2017 for Medicare over- and under-payment is 9.750%.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R295FM.pdf
Defending Medical Review Decisions at Administrative Law Judge (ALJ) Hearings
Updates Medicare Program Integrity Manual due to recent changes in the Office of Medicare Hearings and Appeals process, such as restrictions on the number of contractors able to participate during oral testimony and the adoption of the witness role for those cases in which additional support may be sought.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R748PI.pdf
Medicare Quarterly Provider Compliance Newsletter – October 2017
Provide education on how to avoid common billing errors and other erroneous activities when dealing with the Medicare Fee-For-Service (FFS) Program. This quarter’s newsletter addresses Arthroscopic Rotator Cuff Repair (Physicians), CERT errors for Outpatient Hospital Services, and a DME item.
Prohibition on Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program – REVISED
Revised October 18, 2017 to indicate the Provider Remittance Advice and Medicare Summary Notice identifies the QMB status of beneficiaries and exemption from cost-sharing for Part A and B claims processed on or after October 2, 2017. It also recommends how providers can use these and other upcoming system changes to promote compliance with QMB billing requirements.
Fiscal Year (FY) 2018 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes - REVISED
Updates to some financial information, tables, files, and lists.
American Hospital Association (AHA) Letter to Office of Inspector General (OIG)
The AHA request to OIG to implement actions to address fundamental flaws and inaccuracies in the OIG hospital compliance reviews.
http://www.aha.org/advocacy-issues/letter/2017/171002-let-hatton-cms-hospital-compliance-reviews.pdf
Hurricane Nate and Medicare Disaster Related Alabama, Florida, Louisiana and Mississippi Claims
Describes CMS authorized waivers for providers affected by Hurricane Nate.
October 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.3
Quarterly update to the I/OCE which is the program Medicare uses to process claims for all outpatient institutional providers (OPPS and non-OPPS hospitals). This update describes new or changed processing edits.
October 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Quarterly update to the hospital OPPS system. This update includes new/changed codes, directions on billing for Supervised Exercise Therapy (SET) for peripheral artery disease, and a revision to Medicare policy on Upper Eyelid Blepharoplasty and Blepharoptosis Repair.
Screening for Hepatitis B Virus (HBV) Infection (Revision)
Revision includes clarifications for HBV for ESRD patients and pricing of HCPCS G0499.
Internet Only Manual (IOM) Update to Pub. 100-04, Chapter 15 - Ambulance, to Restore Multiple Patients on One Trip Instructions
Restores missing instructions concerning “Multiple Patients on One Trip” to the Medicare Claims Processing Manual.
Revision to Publication 100.06, Chapter 3, Medicare Overpayment Manual, Section 200, Limitation on Recoupment
Updates the Medicare Financial Management Manual section on Limitation on Recoupment Overpayments
Provider-Based Determination (Revision)
Revision related to acceptable checklist.
Updates to Pub. 100-04, Chapter 18 Preventive and Screening Services and Chapter 32 Billing Requirements for Special Services and Publication 100-03, Chapter 1 Coverage Determinations Part 4
Updates to Cardiac Rehab and Intensive Cardiac Rehab Programs to allow a one-time switch from the ICR program to the cardiac rehabilitation program. Policy clarifications regarding Smoking Cessation Services, and Colorectal Cancer Screening.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3848CP.pdf
National Coverage Determination (NCD) for Smoking and Tobacco-Use Cessation Counseling - RETIRED (210.4)
Effective September 30, 2015 Section 210.4 is deleted and the remaining NCD entitled Counseling to Prevent Tobacco Use (210.4.1) remains effective.
2018 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
SNF consolidated billing defines which services are “included” in the SNF payment and which services are “excluded” (can be directly billed to Medicare by other providers). This updates the HCPCS codes edits for 2018.
Fiscal Year (FY) 2018 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes
Implements policy changes for the Fiscal Year (FY) 2018 Inpatient Prospective Payment System (IPPS) and LTCH Prospective Payment System (PPS).
ICD-10-CM FY 2018 Guidelines
These guidelines are approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Associated (AHA), the American Health Information Management Association (AHIMA), CMS, and the National Center for Health Statistics (NCHS). These guidelines are to be used as a companion document to the official version of the ICD_10-CM as published on the NCHS website.
https://www.cdc.gov/nchs/icd/icd10cm.htm
Office of Inspector General Report: Medicare Inappropriately Paid Acute-Care Hospitals for Outpatient Services they Provided to Beneficiaries who were Inpatients of Other Facilities
The OIG identified outpatient claims from acute-care hospitals that overlapped with the identified inpatient claims from other types of facilities - LTCHs, IRFs, IPFs, and CAHs. The OIG found inappropriate payments of $51.6 million to acute-care hospitals for outpatient services that overlapped inpatient admissions elsewhere.
https://oig.hhs.gov/oas/reports/region9/91602026.pdf
Office of Inspector General Reports Highlight Hospital Billing Issues
Discusses coding concerns for Right Heart Catheterizations (RHCs) with heart biopsies that used modifier -59 and claims for 96 or more continuous hours of mechanical ventilation.
Annual Clotting Factor Furnishing Fee Update 2018
The clotting factor furnishing fee for 2018 is $0.215 per unit. For dates of service from January 1, 2018, through December 31, 2018, the clotting factor furnishing fee of $0.215 per unit is added to the payment limit for the clotting factor.
October 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS) (Revision)
Revised to add or clarify information on Transuretheral Waterjet Prostate Ablation Procedure (CPT code 0421T) and the OPPS status indicator for Q5102.
Billing in Medicare Secondary Payer (MSP) Liability Insurance Situations
Reminder of the fundamental guidance governing billing where liability insurance (including self-insurance) is involved.
Accepting Payment from Patients with a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA), a Liability Insurance Medicare Set-Aside Arrangement (LMSA), or a No-Fault Insurance Medicare Set-Aside Arrangement (NFMSA)
This article explains what a Medicare Set-Aside Arrangement (MSA) is and explains why it is appropriate to accept payment from a patient that has a funded MSA.
Targeted Probe and Educate
CMS is expanding the existing Targeted Probe and Educate (TPE) Pilot to include all MACs in order to reduce appeals, decrease provider burden, and improve the medical review/education process.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1919OTN.pdf
Revisions to the State Operations Manual (SOM) Appendix A– Survey Protocol, Regulations and Interpretive Guidelines for Hospitals
Adds a current regulation with interpretive guidelines not previously included in Appendix A as well as revising interpretive guidelines defining whether a hospital is primarily engaged in providing inpatient services under section 1861(e)(1) of the Social Security Act.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R170SOMA.pdf
Contract Award for A/B MAC Jurisdiction J (posted 9/8/2017)
CMS awarded the Medicare Administrative Contract to Palmetto GBA (Palmetto) for the administration of Medicare Part A and Part B Fee-for-Service (FFS) claims in Jurisdiction J (AL, GA, and TN)
CMS Reveals New Medicare Card Design
The first look at the newly designed Medicare card. The new Medicare card contains a unique, randomly-assigned number that replaces the current Social Security-based number.
The first weekend in September marked the return of college football for another season. Football is a rough sport that requires a lot of padding to prevent and lessen injuries, so football pads are a good thing. If you have ever done home projects that require working on your knees, you quickly realize the value of knee pads. And for long-winded speakers, you hope your chair has a comfortable pad. All of these are good “pads,” but some pads are not so welcome. The extra padding of weight gain and aging is not so good – for example those extra “pads” around your eyes. Peripheral artery disease, abbreviated PAD, is another pad that is bad. The October 2017 update of the Outpatient Prospective Payment System addresses ways Medicare handles these examples of bad “pads.”
Supervised Exercise Therapy (SET) for Peripheral Artery Disease (PAD)
Under a new National Coverage Determination (NCD) effective May 25, 2017, Medicare will pay for supervised exercise therapy (SET) for beneficiaries with intermittent claudication for the treatment of symptomatic peripheral artery disease. The October OPPS update provides details of the requirements and CPT coding for this service.
The Medicare requirements for coverage of SET for PAD are:
- A therapeutic-exercise training program consisting of 30-60 minute sessions,
- Generally up to 36 sessions over 12 weeks,
- Referral from the physician responsible for PAD treatment,
- Contractor discretion for an additional 36 sessions over an extended period of time with a second referral,
- Performed in a hospital setting or physician’s office,
- Delivered by personnel trained in exercise therapy for PAD and who ensure benefits outweigh harms,
- Direct supervision by a physician or non-physician practitioner trained in both basic and advanced life support techniques,
- Patient has no absolute contraindications to exercise as determined by their primary physician, and
- A face-to-face visit with the physician responsible for PAD treatment to obtain:
- The referral for supervised exercise therapy, and
- Information regarding cardiovascular disease and PAD risk factor reduction, such as education, counseling, behavioral interventions, and outcome assessments.
Peripheral artery disease (PAD) rehabilitation is reported with CPT code 93668 for each session. This service is paid under OPPS with a status indicator of “S” (separate APC payment, not discounted when multiple).
Upper Eyelid Blepharoplasty and Blepharoptosis Repair
CMS is revising their policy on blepharoplasty and blepharoptosis when performed together. Before addressing the revision, let’s review the differences in these procedures and the prior policy. Blepharoplasty is removing “pads” (excess fat or skin) around the eye. This is often a cosmetic procedure to improve appearance and cosmetic procedures are not covered by Medicare. Medicare may cover blepharoplasty if there is medical need, such as an injury or the excess skin interferes with vision. Ptosis repair tightens muscles around the eye to raise the height of a drooping eyelid. Medicare’s prior policy, as clarified in the July 2016 OPPS Update, was that any removal of upper eyelid tissue (blepharoplasty) performed in conjunction with a ptosis repair of the same eye was considered a part of the blepharoptosis repair and could not be billed separately to Medicare or to the patient.
Effective October 1, 2017, CMS is revising this policy to allow either cosmetic or medically necessary blepharoplasty to be performed in conjunction with a medically necessary upper eyelid blepharoptosis surgery. This means both procedures can be billed when performed together on the same eye – medically necessary procedures to Medicare and procedures performed for cosmetic reasons to the patient. Patients should be made aware of their financial obligations for cosmetic procedures per Advance Beneficiary Notice (ABN) instructions. If both the ptosis repair and the blepharoplasty are medically necessary and billed to Medicare, the payment for the blepharoplasty is bundled into the comprehensive APC payment for the blepharoptosis. In other words, when Medicare covers both procedures, there is no separate payment for the blepharoplasty.
The article also includes a list of practices related to blepharoplasty and blepharoptosis that are not appropriate for separate payment under Medicare, such as procedures performed on different dates. Please refer to the October 2017 OPPS Update for the full list. You can also find additional information on the original policy clarification in a prior article on this subject.
When billing Medicare for exercise therapy for PAD or blepharoplasty procedures, you need to grab your pad of paper and your favorite padded ink pen, sit in your most comfortable padded chair, and make notes on Medicare’s rules about “pads.”
Debbie Rubio
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.
New Waived Tests
New waived laboratory tests approved by the FDA for performance in a waived laboratory.
NPI for CWF Provider Queries
Beginning January 2018, the CWF Provider Queries will only accept NPIs as Valid Provider Numbers.
Correction to Transfer Payment for MS-DRG 385
CMS is correcting the FISS IPPS Pricer for correct calculation of transfer payments for DRB 385.
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.
NCD 20.8.4 for Leadless Pacemakers
Effective January 1, 2018, Medicare will cover leadless pacemakers when provided in a CMS-approved study.
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.
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.
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)
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
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.
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.
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.
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).
Enforcement of the Partial Hospitalization Program (PHP) 20 Hours per Week Billing Requirement - Rescinded
MLN Matters Article SE1307 was rescinded on August 18, 2017.
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.
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.
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
No hospitals want the Office of Inspector General (OIG) to come knocking on their door. If they do, they will likely find at least some billing errors which will likely result in the need to refund payments. The hospital also has to respond to the OIG findings and give reasons for the errors. These may often sound like excuses, but if there were improper payments, there was a reason, excuse or not. Sometimes the dog does eat the homework. In a recent OIG report concerning outpatient services furnished before or during inpatient stays, hospitals gave the following reasons for incorrect billing.
- They did not understand Medicare requirements,
- Clerical errors, and
- They were not aware the patients were inpatients at other hospitals.
Clerical errors and lack of complete patient information are going to happen. Your hospital can decrease the likelihood of their occurrence by having well-trained employees and sufficient oversight. I think CMS will find the lack of understanding of Medicare rules to be the most egregious of the reasons. It may fall under the “should have known” or “deliberate ignorance” category of excuses. Lack of understanding of Medicare requirements is shaky ground. This is why MMP provides this newsletter and our other services – to help educate providers concerning Medicare requirements – so let’s look at outpatient services furnished before or during inpatient stays.
An inpatient admission includes room and board; nursing and social services; diagnostic, therapeutic, and surgical services; drugs, supplies, and equipment; and transportation services. In fact the only services listed in Chapter One of the Medicare Benefits Manual as not included in the inpatient admission are post-hospital nursing facility services and the professional services of physicians and other practitioners. On occasion, inpatients may have to be sent to another facility to receive services not offered at the host (admitting) hospital. Such services are provided “under arrangements” to the patient – this means:
- the host hospital includes the charges for the services on their inpatient claim to Medicare and
- the host hospital pays the other facility for the services.
There should be clear communication between the hospital and other facilities for any “under arrangement” services so that inappropriate billing does not occur. Inpatients may also go to outpatient departments within the host hospital during their inpatient stay to receive services – these services are included in the inpatient hospitalization and are not separately billable as outpatient services to Medicare.
Medicare has rules that certain outpatient services furnished before an inpatient admission also have to be bundled onto the inpatient claim. This is known as the three-day payment window rule. In general, outpatient services furnished within 3 days prior to and including the date of the patient’s admission are deemed to be inpatient services and included in the inpatient payment. For Medicare there are always nuances to the rules, and this one is no different.
- The rule applies to outpatient services furnished by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital, or by another entity under arrangements with the admitting hospital. This includes the technical portion of services provided at a hospital-owned or hospital-operated physician clinic or practice.
- The patient must have Part A coverage for the rule to apply.
- Ambulance services, maintenance renal dialysis services, and Part A services furnished by skilled nursing facilities, home health agencies, and hospices are excluded from the payment window provisions.
- The 3-day rule applies to IPPS hospitals (hospitals paid under the inpatient prospective payment system). For hospitals and units excluded from IPPS, this provision applies only to services furnished within one day prior to and including the date of the admission (a 1-day rule).
- It is a 3 day rule and NOT a 72 hour rule. Three days means the 3 calendar days prior to admission – for a patient admitted on a Wednesday, the 3 days would be Sunday, Monday, and Tuesday.
- Outpatient services furnished more than 3 days prior to admission, even if part of a single, continuous outpatient encounter prior to admission, are not included on the inpatient claim and may be billed separately on an outpatient claim.
- The rule does not apply to some differently paid entities, such as CAHs, RHCs, and FQHCs. You should read the regulation in Chapter 3, Medicare Claims Processing Manual, section 40.3 for complete information on exclusions.
The 3-day rule is also affected by the type of services provided and whether they are related to the reason for admission or not. I like to break the rule down into three parts for easier understanding.
- All outpatient services (diagnostic and non-diagnostic) subject to the rule that are provided on the day of admission must be billed with the inpatient admission.
- All outpatient diagnostic services provided within the 3- day payment window (or 1-day window for non-IPPS hospitals) must be billed with the inpatient admission.
- Non-diagnostic services related to the inpatient admission and provided within the payment window must be billed with the inpatient admission.
The billing hospital determines and attests if non-diagnostic services furnished on the first, second, or third day prior to admission are unrelated to the inpatient admission. Medicare defines unrelated services as services that are clinically distinct or independent from the reason for the beneficiary’s admission. These “unrelated” services may be billed on a separate outpatient (Part B) claim with a condition code “51” which is the hospital’s attestation the services are unrelated. Documentation in the patient’s medical record must support that the non-diagnostic services provided within the payment window are unrelated to the patient’s inpatient admission.
The section of the Claims Processing Manual referenced above also includes further explanations and definitions of ownership, non-IPPS hospitals, diagnostic services, and more. Providers need to carefully review the guidance in the manual to have a complete understanding of all the requirements for billing outpatient services provided prior to admission.
This advice applies to all Medicare requirements. It is the provider’s responsibility to be knowledgeable of Medicare rules, regulations, and guidance. Remember, not “knowing” or not “understanding” are not good excuses.
Debbie Rubio
TRANSMITTALS
The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year 2015 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long Term Care Hospitals (LTCH)
- MLN Matters Number: MM10026
- Related CR Release Date: June 30, 2017
- Related CR Transmittal Number: R1863OTN
- Related Change Request (CR) Number: CR10026
- Effective Date: July 31, 2017
- Implementation Date: July 31, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10026.pdf
- Affects providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Summary: Informs MACs about updated data for determining the disproportionate share adjustment for Inpatient Prospective Payment System (IPPS) hospitals and the low income patient (LIP) adjustment for IRFs as well as payments as applicable for Long Term Care Hospitals (LTCH) discharges (for example, discharges paid the IPPS comparable amount under the short-stay outlier payment adjustment).
Implementing FISS Updates to Accommodate Section 603 Bipartisan Budget Act of 2015 - Phase 2
- MLN Matters®Number: MM9907
- Related Change Request (CR) #: CR 9907
- Related CR Release Date: February 2, 2017
- Effective Date: January 1, 2017
- Related CR Transmittal #: R1783OTN
- Implementation Date: July 3, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9907.pdf
- Affects Hospital providers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Summary: If a hospital claim is submitted with a service facility location that was not included on the CMS 855A enrollment form, the claim will be Returned to the Provider (RTP) until the CMS 855A enrollment form and claims processing system are updated.
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edits, Version 23.3, Effective October 1, 2017
- MLN Matters Number: MM10183
- Related CR Release Date: July 14, 2017
- Related CR Transmittal Number: R3807CP
- Related Change Request (CR) Number: CR10183
- Effective Date: October 1, 2017
- Implementation Date: October 2, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10183.pdf
- Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Summary: Informs the MACs about the update to the National Correct Coding Initiative (NCCI) procedure to procedure edits (PTP). This notice applies to Chapter 23, Section 20.9 of the Medicare Claims Processing Manual
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2017
- MLN Matters Number: MM10156
- Related CR Release Date: June 16, 2017
- Related CR Transmittal Number: R3797CP
- Related Change Request (CR) Number: CR 10156
- Effective Date: October 1, 2017
- Implementation Date: October 2, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10156.pdf
- Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Summary: Informs MACs about the changes that will be included in the October 2017 quarterly release of the edit module for clinical diagnostic laboratory services.
Clarifying the Instructions for Amending or Correcting Entries in Medical Records
- CR Release Date: July 21, 2017
- CR Transmittal Number: R732PI
- Change Request (CR) Number: CR 10120
- Effective Date: August 22, 2017
- Implementation Date: August 22, 2017
- https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R732PI.pdf
Summary: Clarifies the requirements for a practitioner to authenticate an alteration or revision in the medical records. The contractor shall also accept initials in instances when the author of the alteration must sign and date a revision made.
Notice of New Interest Rate for Medicare Overpayments and Underpayments -4th Qtr Notification for FY 2017
- CR Release Date: July 13, 2017
- CR Transmittal Number: R291FM
- Change Request (CR) Number: CR 10227
- Effective Date: July 18, 2017
- Implementation Date: July 18, 2017
- https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R291FM.pdf
Summary: Medicare Regulation 42 CFR Section 405.378 provides for the charging and payment of interest on overpayments and underpayments to Medicare providers. The Department of the Treasury has notified the Department of Health and Human Services that the private consumer rate has been changed to 10.125 percent.
REVISED TRANSMITTALS
Qualified Medicare Beneficiary Indicator in the Medicare Fee-For-Service Claims Processing System
- In the article, the CR release date, transmittal number, and the Web address of CR9911 are revised. Clarifications are also made to the second paragraph of the Background section.
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9911.pdf
Screening for Hepatitis B Virus (HBV) Infection
- Reflects an updated Change Request (CR) 9859
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9859.pdf
Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)
- Transmittals 196 and 3787, dated May 26, 2017, is being rescinded and replaced by Transmittals 199 and 3805 dated, July 11, 2017 to
- https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R199NCD.pdf
- https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3805CP.pdf
Summary: Update references in the CPM and NCD manuals and to add clarifying language. In the NCD manual, the reference to Pub 100-04, Chapter 32, and Section 68 needs to be changed to Section 69. In the CPM manual, the reference in Pub. 100-04, Chapter 32, Section 68 needs to be changed to Section 69 and clarifying language needs to be added to indicate that CMS will cover procedure code 0275T for PILD only when the procedure is performed within any other CED approved randomized and non-blinded clinical trial. All other information remains the same.
OTHER MEDICARE ANNOUNCEMENTS
Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2018
- July 13, 2017
- https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-07-13-2.html
Summary: The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that includes proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2018.
CMS Proposes Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Changes for 2018, and Releases a Request for Information (CMS-1678-P)
- July 13, 2017
- https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-07-13.html
Summary: The Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule (CMS-1678-P) that includes updates to the 2018 rates and quality provisions, and proposes other policy changes. CMS is proposing a number of policies that would support care delivery; reduce burdens for providers, especially in rural areas; lower beneficiary out of pocket drug costs for several drugs; enhance the patient-doctor relationship; and promote flexibility in healthcare.
Revision of Civil Money Penalty (CMP) Policies and CMP Analytic Tool
- July 07, 2017
- Memorandum
Summary: This policy memo replaces S&C Memo 15-16-NH. When noncompliance exists, enforcement remedies, such as civil money penalties (CMPs), are intended to promote a swift return to substantial compliance for a sustained period of time, preventing future noncompliance. To increase national consistency in imposing CMPs, the Centers for Medicare & Medicaid Services (CMS) is revising the CMP analytic tool.
Medicare Quarterly Provider Compliance Newsletter [Volume 7, Issue 4]
Summary: Educational newsletter. This quarter’s focus is on Cert Findings regarding Skilled Nursing Facility (SNF) Certification and Re-certification and OIG Findings regarding Studies of Hospital Billings of use of Modifier 59 on Heart Biopsy Claims and Procedure Coding for Ventilation Support Claims
A Medicare patient presents to your hospital’s Emergency Department late one evening and immediately requires emergency surgery. The procedure performed in the operating room is on Medicare’s inpatient-only list. Due to the focus on the medical care and treatment of the patient, an order to admit the patient as an inpatient is not obtained until the next morning. Can the inpatient-only procedure be reported on the inpatient claim according to the policy for the payment window for outpatient services treated as inpatient services?
This question was recently posed to Medical Management Plus by one of our clients. I was sure I remembered that Medicare changed an older instruction and now allows the billing of an inpatient-only procedure on the inpatient claim under the 3-day payment window rule. To confirm this, I read the relevant sections in Chapter 4 of the Medicare Claims Processing Manual, which are Section 10.2 about the payment window and Section 180.7 about inpatient-only services. Neither section states that combining an inpatient-only procedure performed on an outpatient basis into the succeeding inpatient admission for payment is allowed. But I am sure I remembered that - have I lost my mind?
I started back-tracking through old transmittals. I noticed Section 180.7 was last updated January 1, 2016, but a review of that transmittal (Transmittal 3425, CR9486) shows the update was related to the comprehensive payment when a patient has an inpatient-only procedure performed and then expires or is transferred prior to an inpatient order being written. After further searching, I finally located Transmittal 3238, CR 9097. This transmittal states:
“Effective April 1, 2015, inpatient only procedures that are provided to a patient in the outpatient setting on the date of the inpatient admission or during the 3 calendar days (or 1 calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission that would otherwise be deemed related to the admission, according to our policy for the payment window for outpatient services treated as inpatient services will be covered by CMS and are eligible to be bundled into the billing of the inpatient admission.” (emphasis added)
This is definitely what I was looking for, but the danger in relying on prior transmittals is they may no longer be effective. That is why I always confirm any transmittal guidance against the actual manuals. And remember, I did not find this verbiage in the manuals. I noticed in the updated manual instructions accompanying this transmittal that there is no “red text” (updated instructions) for these two manual sections other than the ‘update’ dates. As Alice in Wonderland would say, my investigation was getting “curiouser and curiouser.” If nothing was added or changed for these manual sections, was something removed? Exactly what was updated? My search continued.
I finally found (thanks to some old email correspondence) Transmittal 2234, CR 7443 from way back in 2011. It is the July 2011 OPPS Update transmittal and it includes the following revisions. Added to both manual sections noted above is the statement – “inpatient only procedures that are provided to a patient in the outpatient setting on the date of the patient’s inpatient admission or during the 3 calendar days (or 1 calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission that would otherwise be deemed related to the admission are not paid for by CMS and must be submitted on a no-pay claim (Type of Bill (TOB) 110).” Now the April 2015 update made sense! Nothing was added or changed, but the above statement was removed from both manual sections. And since it is still absent from the manual instructions, its removal stands.
So I wasn’t crazy after all – at least not about this issue. It is acceptable to report an inpatient-only procedure performed on an outpatient basis on the ensuing inpatient admission (within the 3 day payment window) and Medicare will cover this related procedure. In fact, I think the scenario I described above is the perfect example of when this bundling is appropriate. I do not think CMS changed this policy simply to allow hospitals to obtain a late inpatient admission order when they failed to do so in a timely manner. I think this rule change was intended to allow appropriate payment in the case of emergencies or when the outpatient surgical procedure intended must be changed to one that is on the inpatient-only list during the surgery.
I am glad CMS made this change, but I wish they had ‘included’ rather than ‘excluded’ instructions in the manual updates. Then I would not have gone looking for something that was not there.
Debbie Rubio
TRANSMITTALS
Update FISS Editing to Include the Admitting Diagnosis Code Field
- MLN Matters® Number: MM9753
- Related Change Request (CR) #: CR 9753
- Related CR Release Date: April 28, 2017
- Effective Date: October 1, 2017
- Related CR Transmittal #: R1832OTN
- Implementation Date: October 2, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9753.pdf
- Affects providers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.
Summary: Updates various system edits to look at the admitting diagnosis field. FISS editing is now being updated to ensure that all of the National Coverage Determination (NCD) edits within Reason Code ranges 3xxxx and 59xxx that are tied to the diagnosis code fields (other than the primary diagnosis field) include the admitting diagnosis field for Inpatient claims on Types of Bill (TOB) 011x, 012x, 018x, 021x, and 022x.
Screening for Hepatitis B Virus (HBV) Infection
- MLN Matters® Number: MM9859
- Related Change Request (CR) #: CR 9859
- Related CR Release Date: April 28, 2017
- Effective Date: September 28, 2016
- Related CR Transmittal #: R3761CP and R195NCD
- Implementation Date: January 1, 2018
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9859.pdf
- Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries
Summary: Medicare will cover screening for Hepatitis B Virus (HBV) infection for certain individuals when performed with an FDA approved/cleared laboratory tests
REVISED: Revision to clarify language on page 3, under the “Professional Billing Requirements.” It now reads, only when services are ordered by the following provider specialties found on the provider’s enrollment record…
Implementing the Remittance Advice Messaging for the 20 Hour Weekly Minimum for Partial Hospitalization Program Services
- MLN Matters® Number: MM9880
- Related Change Request (CR) #: CR 9880
- Related CR Release Date: April 28, 2017
- Effective Date: October 1, 2017
- Related CR Transmittal #: R1833OTN
- Implementation Date: October 2, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9880.pdf
- Affects Outpatient Prospective Payment System (OPPS) providers submitting Partial Hospitalization Program (PHP) claims to Medicare Administrative Contractors (MACs) for PHP services provided to Medicare beneficiaries.
Summary: Implements informational messaging, effective October 1, 2017, that conveys supplemental and educational information to the provider submitting claims for PHP services where the patient did not receive the minimum 20 hours per week of therapeutic services his plan of care indicates is required, on claims with line item date of service (LIDOS) on or after October 1, 2017.
New Physician Specialty Code for Advanced Heart Failure and Transplant Cardiology, Medical Toxicology, and Hematopoietic Cell Transplantation and Cellular Therapy
- MLN Matters® Number: MM9957
- Related CR Release Date: April 28, 2017
- Related CR Transmittal #: R283FM and R3762CP
- Related Change Request (CR) #: CR 9957
- Effective Date: October 1, 2017
- Implementation Date: October 2, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9957.pdf
- Affects physicians and providers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries
Summary: Establishes new physician specialty codes for Advanced Heart Failure and Transplant Cardiology (C7), Medical Toxicology (C8), and Hematopoietic Cell Transplantation and Cellular Therapy (C9).
Payment for Moderate Sedation Services Furnished with Colorectal Cancer Screening Tests
- MLN Matters Number: MM10075
- Related CR Release Date: April 28, 2017
- Related CR Transmittal Number: R3763CP
- Related Change Request (CR) Number: 10075
- Effective Date: January 1, 2017
- Implementation Date: October 2, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10075.pdf
- Affects physicians and other providers submitting claims to Part A and B Medicare Administrative Contractors (MACs) for sedation services furnished with colorectal cancer screening tests.
Summary: Ensures accurate program payment for moderate sedation services furnished in conjunction with screening colonoscopy services for which the beneficiary should not be charged the coinsurance or deductible.
Office of Inspector General Report: Stem Cell Transplantation
- MLN Matters® Number: SE1624 Revised
- Article Release Date: May 1, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1624.pdf
Summary: This article was revised on May 1, 2017, to make a number of clarifications and to delete the table that had been in the article.
Update FISS Editing to Include All Three Patient Reason for Visit Code Fields
- MLN Matters® Number: MM9672 - Revised
- Related Change Request (CR) #: CR 9672
- Related CR Release Date: May 17, 2017
- Effective Date: Claims received on or after October 1, 2017
- Related CR Transmittal #: R1852OTN
- Implementation Date: October 2, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9672.pdf
- Affects providers submitting outpatient hospital claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.
Summary: FISS edits to ensure all of the National Coverage Determination (NCD) edits within Reason Code ranges 3xxxx and 59xxx are tied to the diagnosis code fields including all three Patient Reason for Visit (PRV) fields for outpatient hospital claims on Types of Bills (TOB) 013x and 085x. CR9672 makes no policy changes.
New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare SetAside Arrangements (NFMSAs)
- MLN Matters® Number: MM9893
- Revised Related Change Request (CR) #: CR 9893
- Related CR Release Date: May 10, 2017
- Effective Date: October 1, 2017
- Related CR Transmittal #: R1845OTN
- Implementation Date: October 2, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9893.pdf
- Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.
Summary: Establishes two (2) new set-aside processes: a Liability Insurance Medicare Set-Aside Arrangement (LMSA), and a No-Fault Insurance Medicare Set-Aside Arrangement (NFMSA).
Clarifying Medical Review of Hospital Claims for Part A Payment
- MLN Matters Number: MM10080
- Related CR Release Date: May 12, 2017
- Related CR Transmittal Number: R716PI
- Related Change Request (CR) # 10080
- Effective Date: June 13, 2017
- Implementation Date: June 13, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10080.pdf
- Affects providers that submit institutional claims to Medicare Administrative Contractors (MACs) for inpatient hospital services provided to Medicare beneficiaries.
Summary: Clarifies the medical review requirements for Part A payment of short stay hospital claims (more commonly referred to as the "Two-Midnight" Rule) for MACs, Supplemental Medical Review Contractors (SMRC), Recovery Audit Contractors and the Comprehensive Error Rate Testing (CERT) contractors.
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2017 Update
- MLN Matters Number: MM10107
- Related CR Release Date: May 18, 2017
- Related CR Transmittal Number: R3776CP
- Related Change Request (CR) Number: CR 10107
- Effective Date: July 1, 2017
- Implementation Date: July 3, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10107.pdf
- Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries
Summary: The HCPCS code set is updated on a quarterly basis. Change Request (CR) 10107 informs MACs of updating specific drug/biological HCPCS codes.
July 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.2
MLN Matters Number: MM10115
- Related CR Release Date: May 18, 2017
- Related CR Transmittal Number: R3777CP
- Related Change Request (CR) Number: 10115
- Effective Date: July1, 2017
- Implementation Date: July 3, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10115.pdf
- Affects providers who submit claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH+H) MACs, for services provided to Medicare beneficiaries.
Summary: The I/OCE is being updated July 1, 2017. The I/OCE routes all institutional outpatient claims (which includes non-Outpatient Prospective Payment System (OPPS) hospital claims) through a single integrated OCE.
OTHER MEDICARE ANNOUNCEMENTS
Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR); Delay of Effective Date
- Published in Federal Register May 19, 2017
- https://www.gpo.gov/fdsys/pkg/FR-2017-05-19/pdf/2017-10340.pdf
Summary: This final rule finalizes May 20, 2017 as the effective date of the rule. It also finalizes a delay of the applicability date of the regulations from July 1, 2017 to January 1, 2018.
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