Knowledge Base Category -

May 28, 2024: CMS Updates to Include Marriage and Family Therapists and Mental Health Counselors for Hospice, Rural Health Clinics, and Federally Qualified Health Centers

In the memorandum summary sent to State Survey Agency Directors, CMS notes the CY 2024 PFS final rule updated the Hospice Conditions of Participation, the Rural Health Clinic (RHC) Conditions for Certification, and the Federally Qualified Health Center (FQHC) Conditions for Coverage to implement provisions of the Consolidated Appropriations Act, 2023.

 

For Hospices: The interdisciplinary team must now include at least one social worker, marriage and family therapist or mental health counselor as part of the team. The hospice personnel requirements were updated to add these disciplines.

 

For RHCs and FQHCs: Staffing and personnel requirements were updated to include marriage and family therapists and mental health counselors as part of the collaborative team approach to providing services. Also, definitions of several health care professionals who are already eligible to provide services at RHCs and FQHCs were updated, including the definition of “nurse practitioner,” to align with current standards of professional practice. https://www.cms.gov/files/document/qso-24-12-hospice-fqhc/rhc.pdf

 

Comprehensive Error Rate Testing Program: Reduced Sample Size Starting Reporting Year (RY) 2025

The CERT selects a stratified random sample of Part A/B claims submitted to the Medicare Administrative Contractors (MACs). The sample size allows CMS to calculate a national improper payment rate and contractor-and-service-specific improper payment rates. The sample size is considered to reflect all claims processed by the Medicare FFS program in the report period. CMS recently announced that beginning with the RY 2025, the sample size will be permanently reduced from 50,000 to 37,500 claims annually. CMS notes on their CERT webpage that “it is important to note that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements.”

 

June 7, 2024: FDA Approves Expanded Age Indication for GSK’s Arexvy

GSK noted in their announcement that “over 13 million US adults aged 50-59 have a medical condition that increased their risk of RSV outcomes.” Further, the US FDA has approved Arexvy (Respiratory Syncytial Virus (RSV) Vaccine, Adjuvanted) for the prevention of RSV lower respiratory tract disease (LRTD) in adults 50 through 59 years who are at increased risk for example, adults with COPD, asthma, heart failure and/or diabetes.

• June 7, 2024 FDA Letter to GlaxoSmithKline (GSK) Biologicals: https://www.fda.gov/media/179248/download?attachment=&utm_medium=email&utm_source=govdelivery

 

June 10, 2024: OIG Semiannual Report to Congress

OIG released their semiannual report for the 6-month period ending March 31, 2024. Inspector General Christi A. Grim notes that OIG used experts and authorities, highly developed data analysis techniques, and strong partnerships with other law enforcement and oversight entities, OIG identified $2.76 billion in expected recoveries and issued 195 recommendations and completed 60 audits and 18 evaluations in this reporting period. Inspector General Grim went on to indicate that OIG’s health care work consistently yields a positive return on investment of around $10 returned to every $1 invested. https://oig.hhs.gov/documents/sar/9905/Spring_2024_SAR.pdf

 

June 11, 2024: Long COVID Defined

The National Academies of Sciences, Engineering, and Medicine (NASEM) released a new definition for “Long COVID” – “that it is an infection-associated chronic condition that occurs after COVID-19 infection and is present for at least three months as a continuous, relapsing and remitting, or progressive disease state that affects one or more organ systems.” https://www.nationalacademies.org/news/2024/06/federal-government-clinicians-employers-and-others-should-adopt-new-definition-for-long-covid-to-aid-in-consistent-diagnosis-documentation-and-treatment

 

June 20, 2024 MLN Connects: Watch out for Medicare Record Request Phishing Scam

CMS notes they have identified phishing scams for medical records. In the June 20^th edition of MLN Connects they provide an example, signs of a scam to look for in a request. https://www.cms.gov/training-education/medicare-learning-network/newsletter/2024-06-20-mlnc

On June 13, the OIG published the report CMS Could Strengthen Program Safeguards To Prevent and Detect Improper Medicare Payments for Short Inpatient Stays. This audit was initiated to assess program safeguards for ensuring that Medicare claims for short inpatient stays complied with Medicare Requirements.

 

Two-Midnight Rule

It is hard to believe that so much time has passed since the Two-Midnight Rule went into effect on October 1, 2013. In general, when a hospital stay does not span two midnights, inpatient status is not appropriate. There are caveats, for example, procedures designated as “inpatient only” are appropriate for inpatient billing regardless of the length of stay.

 

Post two-midnight rule implementation, the OIG concluded in a report that “hospitals were still billing for many short inpatient stays that were potentially inappropriate under the two-midnight rule, and Medicare paid almost $2.9 billion for these stays.” At that time, CMS agreed with the OIG recommendation that they improve oversight of hospital billing under the two-midnight rule.

 

About the June 13, 2024 13 OIG Report

The OIG focused on program safeguards for short inpatient stays for calendar years 2016 through 2020. Program safeguards used by CMS and it contractors include measuring improper payment rates through the Comprehensive Error Rate Testing (CERT) Program, implementing claims processing edits, and conducting post payment review claims. The audit covered:

• $19.7 billion in Medicare Part A claims, and
• 2.5 million short inpatient stays at 3,340 acute-care hospitals.

  After the two-midnight rule went into effect, the CERT added a table to their supplemental improper payment data highlighting projected improper payments by length of stay. The first year this was reported the 0- or 1-day stays projected improper payment rate was 27.8% with a projected improper payment of $2.1B. In the December 2023 data, the 0- or 1-day stays improper payment rate remained high at 21.7% with a projected improper payment of $1.7B.

   

  Report Conclusion

  Three weaknesses in the established program safeguards for preventing and detecting improper payments for short inpatient stays and recovering payments. Specifically, the OIG concluded that CMS did not have:

• Adequate information to identify short inpatient stays at risk for noncompliance with the two-midnight rule,
• Prepayment edits for claims at risk for noncompliance with the two-midnight rule, and
• Adequate policies and procedures to review claims at risk for noncompliance with the two-midnight rule and to recover payments.

 

Weaknesses occurred from CMS mostly relying on post payment reviews by BFCC-QIOs to ensure compliance with the two-midnight rule. Although thousands of claims were reviewed and denied $49.2 million in improper payments during the audit period, this represents only 0.6 percent of the $7.8 billion in improper payments estimated by CMS CERT reviews.

 

Recommendations to CMS

The OIG made the following four recommendations to CMS:

• Add information to inpatient claims indicating any stay that did not span two or more midnights because of an unforeseen circumstance,
• Develop a list of inpatient-only procedure codes associated with the outpatient procedure codes on the inpatient-only procedure list,
• Implement prepayment edits for claims for short inpatient stays at risk for noncompliance with the two-midnight rule, and
• Update policies and procedures for post payment reviews to focus on claims for short inpatient stays identified as at risk for noncompliance with the two-midnight rule and to focus on overpayment recoveries.

CMS Response to Recommendations

CMS neither agreed nor disagreed with the OIG recommendations, merely stating that they will take them into consideration as it determines appropriate next steps.

 

I would not get too excited about the recommendation to develop a list of inpatient-only procedure codes associated with outpatient procedure codes on the inpatient-only procedure list. MMP clients have often asked if there was such a list available as hospitals work to identify inpatient-only procedures. Currently, there is no such list. Also, I agree with CMS in that this task would be a challenge as “the ICD-10 and HCPCS code sets are intended to reflect and represent services in different healthcare settings that there would limitations in developing a one-to-one mapping.”

 

In the meantime, I encourage you to take the time to read this report in its entirety for additional information regarding the OIGs findings, the BFCC QIO 2 Midnight Claim Review Guideline that Livanta, the National Medicare Claim Review Contractor, utilizes in performing short stay audits nationwide, and CMS comments in response to the OIG’s recommendations. 

The OIG’s updates its Work Plan on their website monthly and they have indicated that their “work planning process is dynamic, and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available.”

For June 2024, the OIG has added eleven items to their Work Plan. One of the items of interest for hospitals is titled Medicare Enrollees Leaving Hospitals Against Medical Advice. The OIG notes that “according to some academic researchers, the AMA designation indicates a higher risk that a patient experienced poor quality health care. The researchers also note that hospital stays coded with the AMA designation may be associated with increased patient morbidity and mortality percentage rates. In addition, the researchers note that historically medically underserved groups of patients are more likely than other groups to receive the AMA designation. The percentage rates that hospitals have been designating that Medicare enrollees left AMA have increased over the past three decades. This data brief will analyze the percentage rates and outcomes for enrollees that hospitals designate as left AMA as well as provide CMS and other stakeholders with information that can be used to address health disparities and improve enrollee outcomes.”

The OIG is expected to issue a report in FY 2025. In the meantime, I turned to our sister company, RealTime Medicare Data (RTMD) to learn about this group of Medicare beneficiaries in CY 2023. The RTMD database includes paid claims data for all fifty states and Washington D.C.

The following insights were pulled from all Medicare Fee-For-Service paid claims in calendar year 2023 with a discharge disposition code of “07” which stands for “left against medical advice or discontinued care.” 

All Claims with Discharge Disposition “07”

Volume: 72,370

Total Payment: $779,351,684.25

Average Payment: $10,769.14

ALOS: 3.054 Days

 

Surgical Claims with Discharge Disposition 07

Surgical Volume: 5,021

Total Payment: $134,587,109.49

Average Payment: $26,810.18

ALOS: 6.089

 

Top 5 MDCs by Surgical Volume

MDC 5: Circulatory System: 1,335 claims

MDC 8: Musculoskeletal System & Connective Tissue: 828 claims

MDC 18: Infectious & Parasitic Disease: 517 claims

MDC 6: Digestive System: 411 claims

MDC 11: Kidney & Urinary Tract: 363 claims

 

Top Surgical MS-DRG Group: MS-DRGs 853 and 854: Infectious & Parasitic Diseases with O.R. Procedures with and without MCC: 465 claims

 

Top 5 Provider States by Surgical Volume

California: 734 claims

Florida: 575 claims

Texas: 372 claims

New York: 354 Claims

Pennsylvania: 188 claims

 

Medical Claims with Discharge Disposition 07

Medical Volume: 67,349

Total Payment: $644,764,574.76

Average Payment: $9,573.48

ALOS: 2.82

 

Top 5 MDCs by Medical Volume:

MDC 5: Circulatory System: 13,664 claims

MDC 4: Respiratory System: 7,808 claims

MDC 1: Nervous System: 5,976 claims

MDC 6: Digestive System: 5,860 claims

MDC 18: Infectious & Parasitic Diseases: 5,692 claims

 

Top MS-DRG Pair: MS-DRGs 871 and 872: Septicemia or Severe Sepsis without MV >96 hours with and without MCC respectively: 5,320 claims

 

Top 5 Provider States by Medical Volume

California: 9,962 claims

Florida: 8,334 claims

New York: 5,595 claims

Texas: 5,330 claims

Pennsylvania: 2,334 claims

 

Social Determinants of Health and Discharge Disposition 07

As mentioned previously, “researchers note that historically medically underserved groups of patients are more likely than other groups to receive the AMA designation.”

 

Social determinants of health (SDOH) are the conditions in the environment where people are born, live, learn, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. ¹ For this reason, I also looked for claims with a Social Determinant of Health (SDOH) Z code listed as a secondary diagnosis.

 

Out of this group of claims where the beneficiary left AMA, 3,519 Z-Codes were listed as a secondary diagnosis. Note, there were claims where more than one Z code had been coded so this number does not represent 3,519 individual Medicare beneficiaries. That said, there were 2,354 unique claims where one of the homelessness Z-codes was on the claim and 24 unique claims where one of the inadequate housing Z-codes were on the claim.

 

Resource

U.S. Department of Health and Human Services: Office of Disease Prevention and Health Promotion: Health People 2030: Social Determinants of Health webpage: https://health.gov/healthypeople/priority-areas/social-determinants-health

Did You Know?

CMS published the FY 2025 ICD-10-PCS files on June 5, 2024. There were no changes made to the Official ICD-10-PCS Coding Guidelines for October 1, 2024.

 

For FY 2025 there are 371 new codes, no revised codes, and sixty-one deleted codes bringing the total number of ICD-10-PCS codes to 78,948.

 

Section X New Technology Codes

In FY 2016, a new section X New Technology was created to classify new technology procedures. In FY 2016 there were fourteen section X codes. For FY 2025 there are now 378 section X codes.

 

Beginning with FY 2024, CMS began posting the new technology applications publicly to increase transparency and enable increased stakeholder engagement. The NTAP Public Application Summaries are available on the Medicare Electronic Application Requests Information System™ (MEARIS™).

 

Changes to the codes will be in effect for discharges occurring from October 1, 2024, through September 30, 2025.

 

Why it matters?

CMS notes, on the opening page of the 2025 ICD-10-PCS Official Guidelines for Coding and Reporting, “These guidelines have been developed to assist both the healthcare provider and the coder in identifying those procedures that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.”

 

What can I do?

Share this information with coding and clinical documentation professionals at your facility as you begin to prepare for the October 1, 2024, start of the CMS FY 2025. Even though there were no changes made to the Official ICD-10-PCS Coding Guidelines, I consider an annual review a worthwhile part of your summer reading.

Resource

CMS.gov: 2025 ICD-10-PCS webpage: https://www.cms.gov/medicare/coding-billing/icd-10-codes/2025-icd-10-pcs

Question:

Do we assign a code for underdosing of medication when the patient takes it on an “as needed” basis only?

 

Answer:

Per Coding Clinic, First Quarter, 2021, pages 12-13, PRN medications are not classified as long-term drug therapy; therefore, a code for underdosing of a PRN medication should not be assigned when it is not being taken.  However, the ICD-10-CM Z code for Patient’s noncompliance with other medical treatment and regimen for other reason (Z91.198) can be assigned. This ICD-10-CM diagnosis code became effective October 1, 2023.

 

References:

Coding Clinic for ICD-10-CM/PCS, First Quarter 2021:  Pages 12-13

Did You Know?

In 2023, the Medicare Administrative Contractors (MACs) came together for a multi-MAC collaboration to provide an evidence-based Local Coverage Determination (LCD) for cervical fusion.

 

Why it Matters?

Historically, there have been LCDs for back procedures for Cervical Disk Replacement (i.e., Palmetto GBA LCD L38033), Lumbar Artificial Disc Replacement (i.e., Palmetto GBA LCD L37826), and Lumbar Spinal Fusion (i.e., Palmetto GBA LCD L37826).

 

Cervical Fusion is new to this group of back procedure LCDs, and the original effective date for this new LCD is July 7, 2024.

 

Per Palmetto’s LCD, cervical fusion surgery is considered medically reasonable and necessary when one of three covered indications:

1. For decompression of symptomatic cervical nerve root impingement,
2. For decompression of symptomatic cervical canal stenosis, or
3. For decompression or stabilization of the cervical spine for one of four indications (traumatic injuries, spinal tumors, infection, deformities that include the cervical spine.)

 

In addition to meeting one of the above three indications, there are specific requirements for each that also must be met.  

 

What Can You Do?

Find your MAC specific LCD and related Billing and Coding Article on the Medicare Coverage Database (MCD) and share this information with key stakeholders at your facility. Below are the MAC specific policies and related articles listed on the MCD as of June 3^rd.   

 

MAC Specific Cervical Fusion LCD and related Billing and Coding Article

CGS J14: L39741 / A59608 (A59738 – Response to Comments Article)

First Coast JN: DL39799

NGS J6/JK: DL39770 / DA59632

Noridian JE: L39758 / A59624 (A59796 – Response to Comments Article)

Noridian JF: L39762 / A59645 (A59797 – Response to Comments Article)

Novitas JH/JL: DL39793

Palmetto JJ/JM: L39773 / A59634 (A59736 – Response to Comments Article)

WPS J5/J8: L39788 / A59664 (A59800 – Response to Comments Article)

Did You Know?

June is cataract awareness month and according to the National Eye Institute (https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/cataracts), most cataracts are age-related, there are no early symptoms of cataracts and later symptoms includes blurry vision, colors that seem faded, sensitivity to light, trouble seeing at night and double vision.

 

In addition to age, you may be at a higher risk of developing cataracts if you:

• Have certain health problems like diabetes
• Smoke
• Drink too much alcohol
• Have a family history of cataracts
• Have had an eye injury, eye surgery, or radiation treatment on your upper body
• Have spent a lot of time in the sun
• Take steroids

 

A cataract is diagnosed by a dilated eye exam and the treatment is surgery. Cataract surgery is one of the most common operations in the United States. In fact, more than half of all Americans aged eighty or older either have cataracts or have had surgery to get rid of cataracts.

 

Why it Matters?

Being a high-volume surgery means scrutiny by CMS and Medicare Contractors to assure documentation in the medical record supports medical necessity of the procedure.

 

Recovery Audit Contractors

RAC Issue 0002 Cataract Removal has been an approved complex review for procedures performed in the outpatient hospital setting and ambulatory surgery centers (ASCs) since February 1, 2017. RACs will review documentation to determine if cataract surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Applicable National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) are included on this RAC issue webpage.

 

Comprehensive Error Rate Testing (CERT)

In the 2023 CERT Medicare Fee-for-Service supplemental improper payment report, cataract removal and lens insertion is listed in Table G1: Improper Payment Rates by Service Type: Part B. The improper payment rate was 8.2% with the projected improper payment of $149,241,566.

 

Medicare Administrative Contractors (MACs)

JE and JF MAC: Noridian

Cataract surgery has been a review target for Noridian MAC jurisdictions for a few years. Their most recent review findings were published on April 15, 2024 for claims with dates of service from January 1, 2024 through March 31, 2024:  

• Noridian JE error rate was 22% down from 48.67% in April 2023.
• Noridian JF was 43.6% down from error rate 45.88% in April 2023.

 

Noridian’s review results articles include top denial reasons, educational resources, and education regarding the medical necessity for cataract surgery.

 

What Can You Do?

With so many entities focused on reviewing cataract surgery claims, moving forward providers should:

• Respond to ADRs in a timely manner,
• Become familiar with medical necessity indications and documentation requirements detailed in Medicare coverage documents (NCDs, LCDs, LCAs),
• Be aware of who is performing cataract surgery reviews,
• Read published review results to understand reasons for denials and ways to prevent future denials, and
• Ensure physicians performing these procedures are also aware of Medicare coverage requirements.

Medicare Transmittals & MLN Articles

April 25, 2024: MLN MM13449: Stay of Enrollment – Revised

This article provides information about a new provider enrollment status called a stay of enrollment and related updates to the Medicare Program Integrity Manual, Chapter 10. On April 25^th, CMS reissued this article to revise the effective and implementation dates to May 30, 2024 and the web address of Change Request (CR) 13449. https://www.cms.gov/files/document/mm13449-stay-enrollment.pdf

 

May 3, 2024: MLN MM13487: Diabetes Screening & Definitions Update: CY 2024 Physician Fee Schedule Final Rule

CMS advises providers to make sure your billing staff knows about the revised regulatory definition of diabetes, the revised diabetes screening frequency limitations, and coverage of the Hemoglobin A1C (HbA1c) test for diabetes screening.

 

Prior to January 1, 2024 the HbA1C test (HCPCS code 83036) was covered for the purpose of diabetes management but not for diabetes screening. As of January 1, 2024, CMS now covers the HbA1c test for diabetes screening. https://www.cms.gov/files/document/mm13487-diabetes-screening-definitions-update-cy-2024-physician-fee-schedule-final-rule.pdf

 

May 3, 2024: MLN MM13486: Annual Wellness Visit: Social Determinants of Health Risk Assessment

Make sure your billing staff knows that the social determinants of health (SDOH) risk assessment is now an optional annual wellness visit (AWV) element and what the eligibility and billing requirements are for completing the SDOH risk assessment as part of the AWV. https://www.cms.gov/files/document/mm13486-annual-wellness-visit-social-determinants-health-risk-assessment.pdf

 

May 3, 2024: MLN MM13592: Updates for Split or Shared Evaluation & Management Visits

Information in this article for your billing staff include the definition of split or shared visit and substantive portion, and how to bill appropriately for split or shared evaluation and management (E/M) visits. https://www.cms.gov/files/document/mm13592-updates-split-or-shared-evaluation-management-visits.pdf

 

May 9, 2024: MLN MM13608: ESRD Prospective Payment System Quarterly Update

Make sure your billing staff knows about the Transitional Drug Add-On Payment Adjustment (TDAPA) for HCPCS code J0911 and the updated list of outlier services under the ESRD PPS. https://www.cms.gov/files/document/mm13608-esrd-prospective-payment-system-quarterly-update.pdf

 

May 16, 2024: MLN MM13617: Medicare Claims Processing Manual Update: Gap-Filling DMEPOS Fees

Make sure your billing staff knows about the revised Section 60.3 in the Medicare Claims Processing Manual, Chapter 23 and updated factors for gap-filling purposes.

https://www.cms.gov/files/document/mm13617-medicare-claims-processing-manual-update-gap-filling-dmepos-fees.pdf

 

May 23, 2024: MLN MM13598: NCD 200.3 – Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (AD)

This article includes information about FDA-approved monoclonal antibodies, the criteria for coverage, coding information, and claims processing instructions. https://www.cms.gov/files/document/mm13598-national-coverage-determination-2003-monoclonal-antibodies-treatment-alzheimers-disease.pdf

 

May 24, 2024: MLN MM13613: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update

This article was initially released on May 3^rd, 2024 with guidance from CMS to make sure your billing staff know that the next private payor data reporting period of January 1, 2025 – March 31, 2025 and new and deleted HCPCS codes. No substantive changes were made in the May 24^th revision other than to update the web address of the CR transmittal. https://www.cms.gov/files/document/mm13613-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf

Coverage Updates

April 30, 2024: New National Coverage Analysis (NCA)Tracking Sheet for Implanted Pulmonary Artery Pressure Sensor for Heart Failure Management (CAG-00466N)

CMS posted a National Coverage Analysis (NCA) Tracking Sheet regarding a request from Abbott to provide coverage for the CardioMEMS™ HF System. This device measures Pulmonary artery (PA) pressures by using a combination of an implantable PA pressure sensor and a remote hemodynamic monitoring system that is accessible by the physician. CMS is soliciting public comment until May 30, 2024 and has indicated a proposed Decision Memo due date of October 30, 2024. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=313

 

May 2, 2024: CMS Statement on Proposed LCD for Skin Substitute Grafts/Cellular and Tissue-Based Products for Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

CMS notes in the May 2, 2024 edition of MLN Connects that they are aware of the MACs having issued a collaborative proposed Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers Local Coverage Determination (LCD). CMS strongly encourages interested parties to provide comments during the public comment period that is open until June 8, 2024.  

 

May 10, 2024: MLN MM13596: ICD-10 & Other Coding Revisions to National Coverage Determinations: October 2024 Update

This article highlights new codes and recent coding changes related to the Next Generation Sequencing (NGS) (NCD 90.2), Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity (NCD 100.1), and the Aprepitant for Chemotherapy-Induced Emesis (NCD 110.18). https://www.cms.gov/files/document/mm13596-icd-10-other-coding-revisions-national-coverage-determinations-october-2024-update.pdf

 

May 13, 2024: MLN MM13604: National Coverage Determination 110.23: Allogeneic Hematopoietic Stem Cell Transplantation

Make sure your billing staff knows about coverage for HSCT using bone marrow, peripheral blood or umbilical cord blood stem cell products for Medicare patients and all other indications for stem cell transplantation not otherwise specified. https://www.cms.gov/files/document/mm13604-national-coverage-determination-11023-allogeneic-hematopoietic-stem-cell-transplantation.pdf

 

Compliance Education Updates

May 2024: MLN Fact Sheet: Swing Bed Services

CMS has updated this fact sheet to include information about covered Critical Access Hospital (CAH) swing bed services.  https://www.cms.gov/files/document/mln006951-swing-bed-services.pdf

 

Other Updates

May 9, 2024: CMS Publication – Part B Drug Payment Limits Overview

In the Thursday, May 9^th edition of MLN Connects, CMS noted they have published a Part B Drug Payment Limits Overview document to explain the Average Sales Price (ASP) payment limit calculation and other Medicare Part B drug payment methodologies including Wholesale Acquisition Cost (WAC), Average Wholesale Price (AWP), Average Manufacturer Price (AMP), Widely Available Market Price (WAMP), and Contractor Pricing.  

 

May 9, 2024: Mental Health: It’s Important at Every Stage of Life

Also in the Thursday, May 9^th edition of MLN Connects, CMS noted that mental and physical health are equally important components of overall health, and they provide links to information about appropriate preventive services and preventive services (i.e. Medicare & Mental Health Coverage) covered by Medicare.

 

May 21, 2024: CMS Launches New Option for Individuals to Report Potential Violations of the Emergency Medical Treatment and Labor Act (EMTALA)

CMS announced the launch of a new web resource to educate the public and promote patients’ access to emergency medical care to which they are entitled under federal law. https://www.cms.gov/newsroom/press-releases/biden-harris-administration-launches-new-option-report-potential-violations-federal-law-and-continue

 

Kepro

Kepro’s service areas include CMS Regions 1,4, 6, 8, and 10. In December 2022, Kepro merged with CNSI. Six months later, they announced the organization had been rebranded as Acentra Health indicating that “the name Acentra Health derives from the root words “accelerate” and “central,” reflecting the company’s uncompromising resolve to be a vital partner to public sector health agencies in the delivery of comprehensive healthcare solutions and services, with “Health” being its central business focus.”

 

On April 30, 2024, Kepro published a special bulletin letting providers know about their name change. They encouraged providers to update their beneficiary notices, the Important Message from Medicare (IM) and the Notice of Medicare Non-Coverage (NOMNC), by replacing “Kepro” with “Acentra Health.” However, they did note that notices that still have the name “Kepro” listed will be accepted and validated and posted a list of FAQs on their website about this change. Key things to be aware of include:

 

• Phone numbers and fax numbers will not be changing,
• Their “go live” target date for rebranding to “Acentra Health” is August 1^st and plan to have all their items changed by fall 2024,
• Kepro has been contracted to perform Medicare’s mandatory reviews through 2029 and its CMS Regions will not be changing,
• There will be a new website with a new web address, and will be available when the name change occurs by fall 2024, and
• They encourage you to sign up to their newsletter, Case Review Connections, which includes updates and news from Kepro.

   

  A day after the special bulletin was published, on May 1, 2024, Kepro began a new process for hospital discharge appeals. Specifically, when a Medicare Fee-for-Service beneficiary calls Kepro to file a discharge appeal due to concerns with their discharge planning will be transferred to the Immediate Advocacy (IA) team. This team will review the concerns, identify any gaps or misunderstandings, and determine if additional guidance is needed. You can read more about this new process on Kepro’s Hospital Discharge Appeals webpage.

   

  Livanta

  Livanta’s service areas include CMS Regions 2, 3, 5, 7, and 9. On May 17, 2024 they distributed Provider Bulletin # 21 announcing that they had been awarded the BFCC-QIO contract for case reviews from May 1, 2024, through April 30, 2029. Livanta will also continue to serve as the national Medicare Claim Review contractor.

   

  Livanta’s announcement includes the following four sections:

• Section 1: Beneficiary Case Review versus Claim Review,
• Section 2: What is changing, and what is staying the same?
• Section 3: Updating Contact Information and Memoranda of Agreement, and
• Section 4: Stay in Touch with Livanta.

 

If you are unsure who your BFCC-QIO is, you can use the QIO “Locate Your BFCC-QIO” tool at https://qioprogram.org/locate-your-bfcc-qio.

 

Resource

Livanta Provider Bulletin #21: https://www.livantaqio.cms.gov/assets/files/13-SOW-MD2024-QIOBFCC-PROV-1.pdf