Knowledge Base Category -
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.
Local Medicare Administrative Contractor (MAC) coverage updates during the last month included a new Article from Noridian Jurisdiction E and a combining of existing Parts A and B articles for Noridian JF concerning the topic of Lymphedema Decongestive Treatment. Noridian is the only MAC with a separate Article or Local Coverage Determination (LCD) that specifically addresses this topic. However, almost all the other MACs do address lymphedema treatment as part of their Physical/Occupational Therapy policies. Lymphedema treatment is important to restore normal shape, reduce the likelihood of complications, and to restore function (such as self-care and other activities of daily living [ADLs]).
There are similarities and differences between the coverage policies from the various MACs, so be sure to refer to the policy for your jurisdiction to understand the requirements that apply to your hospital. In general, complex or comprehensive decongestive therapy (CDT) consists of skin care, manual lymphatic drainage (MLD), compression wrapping, and therapeutic exercises. Other key points related to the treatment are listed below.
- There must be a physician-documented diagnosis of primary or secondary lymphedema. Treatment is not for tissue edema from other causes (e.g. congestive heart failure).
- The patient should have documented signs and symptoms and functional limitations due to the lymphedema.
- The ultimate goal of treatment is to reduce and maintain reduction of lymphedema by establishing a management program that can be carried out by the patient, patient’s family, or patient’s caregiver. This means a major component of treatment is education of the patient and/or caregiver.
- Skilled therapy should not be continued once the patient/caregiver has been sufficiently trained.
- It is necessary for the patient or their caregiver to have the ability to understand and comply with continuation of the treatment regimen after skilled therapy is complete.
- Treatment should be provided by a skilled professional (physician, non-physician practitioner, or therapist) who has received specialized training in this form of treatment.
- Almost all the coverage policies place limits on the amount and duration of treatment. Common limits are 3-5 treatments weekly for up to 12-18 visits but vary by MAC.
- Most MACs support the use of CPT code 97140 (manual therapy) for manual lymphatic drainage and CPT 97110 (therapeutic exercise) for the exercise portion of CDT. Some MACs state they do not accept the compression application codes (29581-29584) for compression wrapping for lymphedema.
- Documentation requirements, when addressed, require supportive documentation of patient history and etiology, prior treatments, ability of patient and/or caregiver to continue home treatment, functional limitations and pain levels, limb measurements and any other skin conditions in that area.
Secondary lymphedema may be the result of surgical removal of lymph nodes (such as in association with surgery for breast cancer or other cancers), fibrosis secondary to radiation, and traumatic injury to the lymphatic system. Decongestive therapy for lymphedema is a valuable treatment for those patients who need it. Providers should be familiar with and follow the guidance of their area Medicare contractors for this beneficial service.
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
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
I do not usually write articles about Medicare Coverage Decision Memorandums. This is because Coverage Decision Memos are not binding on contractors or Administrative Law Judges (ALJs) until they are implemented in a CMS-issued program instruction. Formal program instructions are supposed to occur within 180 days of the end of the calendar quarter in which the memo was posted on the Web site. If there are specific coding and billing instructions, they will also be published at the same time in a transmittal that updates the Medicare Claims Processing manual. The effective date of Medicare coverage of a particular service finalized in a National Coverage Determination (NCD) appears to always be made retroactive back to the date of the decision memo. So although the coverage of a service begins at the time of the Decision Memo, providers shouldn’t attempt to bill for the service until a final NCD and any associated billing/coding instructions are released.
This time I am going to make an exception because I think it is very interesting and an excellent Medicare benefit that CMS has decided to cover exercise therapy for patients with peripheral artery disease (PAD). PAD is the buildup of plaque in the arteries causing narrowing and affecting the lower extremities. Approximately 12% of Americans have PAD, but the prevalence increases with age. PAD causes pain and discomfort in the legs when walking or exercising but resolves with rest. This is known as intermittent claudication (IC). IC can dramatically affect patients’ functional independence and quality of life. As with all things Medicare, the minutiae are in the explanation of the coverage requirements.
Medicare will cover supervised exercise therapy (SET) when the following requirements are met:
- For beneficiaries with intermittent claudication (IC) for the treatment of symptomatic peripheral artery disease (PAD);
- Up to 36 sessions over a 12 week period;
- Sessions lasting 30-60 minutes comprising a therapeutic exercise-training program for PAD in patients with claudication;
- In a hospital outpatient setting, or a physician’s office;
- Delivered by qualified auxiliary personnel trained in exercise therapy for PAD to ensure benefits exceed harms; and
- Under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist trained in both basic and advanced life support techniques.
The patient must have a face-to-face visit with and obtain a referral for the SET from the physician treating their PAD. At this visit, the patient must receive information on cardiovascular disease and PAD risk factor reduction. This could include education, counseling, behavioral interventions, and outcome assessments. The Medicare Administrative Contractor may approve 36 additional sessions of SET for PAD based on a second referral. Medicare will not cover SET if a patient’s primary physician determines the patient has an absolute contraindication to exercise.
Exercise therapy is an effective way to alleviate the pain of PAD. SET may also prevent the progression of PAD and lower the risk of cardiovascular events that are prevalent in these patients. Greater access to SET programs could decrease the need for endovascular revascularization (ER) procedures so that ER can be reserved for cases where the patient is too functionally impaired for SET.
Providers should be on the lookout for the NCD and any associated claims processing instructions related to this decision memo.
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.
As of the writing of this article, there are 344 Medicare National Coverage Determinations (NCDs), 1,207 Local Coverage Determinations (LCDs) and 1,197 local Articles. From the Medicare Coverage Determination Process webpage, “Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). National coverage determinations (NCDs) are made through an evidence-based process, with opportunities for public participation. In some cases, CMS' own research is supplemented by an outside technology assessment and/or consultation with the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC). In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD).” LCDs may also be developed when there is a need to further define an NCD. LCDs only contain reasonable and necessary language. Other information related to an item or service that does not deal with the medical necessity of the item/service is communicated through an article. At the end of an LCD that has an associated article, there is a link to the related article and vice versa.
When I first became aware of LCDs in my Compliance career, they were called LMRPs (Local Medical Review Policies). The main concept of LMRPs at the time was of a list of covered diagnoses (defined by, at that time, ICD-9 diagnosis codes). If an item, test, or service that had an LMRP was performed and one of the “covered” diagnosis codes was not on the claim, the line item for the item, test, or service was denied. LCDs still have lists of diagnosis codes (now ICD-10 codes) that support the medical necessity of the services. However, today’s policies go beyond the diagnosis codes and describe the indications and limitations for coverage. And although some LCDs are retired and others created, it seems that LCDs as a whole are addressing a wider range of services than ever before.
For example, National Government Services (NGS), the Medicare Administrative Contractor (MAC) for Jurisdictions J6 and JK, retired their existing policy for Nerve Blocks for Peripheral Neuropathy (L35029) and added a new policy for Peripheral Nerve Blocks (L36850). The older policy only addressed the limitation that nerve blocks for multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases were not considered medically necessary and therefore not covered.
The new policy defines coverage for all possible uses of nerve blocks. This includes a list of seven indications that are reasonable and necessary for coverage and a long discussion of limitations (this includes the original limitation concerning neuropathies). Covered conditions for peripheral nerve blocks include the following. These are shortened descriptions, so please see the policy for complete descriptions.
- classic mononeuritis where neuro-diagnostic studies have failed to provide a structural explanation
- complex regional pain syndrome from peripheral nerve injuries/entrapment or other extremity trauma
- diagnostically for cases in which the clinical picture is unclear
- occipital neuralgia
- suspected entrapment of the suprascapular nerve
- blocked trigeminal nerve
- preemptive analgesia for post-surgical pain control
The limitations discuss frequency, total number of injections, and injections of multiple sites among other issues.
The caution to providers is to no longer rely simply on the presence or absence of a particular diagnosis code to determine coverage of a service. Yes, the diagnosis (and corresponding code) must be present, but coverage requirements go way beyond that. The patient’s condition must meet the indications for a particular service, there must be no limitations to coverage, and the documentation in the patient’s medical record must support the required indications. If not, the service is likely to be denied should a Medicare contractor perform a medical review.
Determining if services provided to Medicare patients meet all the indications of a coverage policy is a lot harder than simply looking for a diagnosis code, both for Medicare and for the provider. This requires a complex medical review by Medicare and internal evaluation of processes and documentation by the provider. It definitely goes beyond the diagnosis code list.
Debbie Rubio
Transmittals
FISS Implementation of the Restructured Clinical Lab Fee Schedule
- MLN Matters® Number: MM9837 Revised
- Related Change Request (CR) #: CR 9837
- Related CR Release Date: March 23, 2017
- Effective Date: January1, 2018
- Related CR Transmittal #: R3740CP
- Implementation Date: July3 , 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9837.pdf
- Affects clinical laboratory providers submitting claims to Medicare Administrative Contractors (MACs) for services paid under the Clinical Lab Fee Schedule (CLFS) and provided to Medicare beneficiaries.
Summary: Informs MACs about the changes to the Fiscal Intermediary Shared System (FISS) to incorporate the revised CLFS containing the National fee schedule rates.
Payment for Moderate Sedation Services
- MLN Matters® Number: MM10001
- Related Change Request (CR) #: CR 10001
- Related CR Release Date: April 14, 2017
- Effective Date: January 1, 2017
- Related CR Transmittal #: R3747CP
- Implementation Date: May 15, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10001.pdf
- Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for moderate sedation and anesthesia services provided to Medicare beneficiaries.
Summary: Revises existing Medicare Claims Processing Manual language to bring the manual in line with current payment policy for moderate sedation and anesthesia services.
Providers should refer to the revised Medicare Claims Processing Manual, Chapter12 (Physicians/Non-physician Practitioners), Sections 50 and 140 for information regarding the reporting of moderate sedation and anesthesia services.
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edits, Version 23.2, Effective July 1, 2017
- MLN Matters Number: MM10082
- Related CR Release Date: April 14, 2017
- Related CR Transmittal Number: R3748CP
- Related Change Request (CR) Number: CR10082
- Effective Date: July1, 2017
- Implementation Date: July 3, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10082.pdf
- Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Summary: Informs about the quarterly update to the National Correct Coding Initiative (NCCI) procedure to procedure edits (PTP).
Other Medicare Announcements
Final Rule Correction – Medicare Physician Fee Schedule
- Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Bid Pricing Data Release; Medicare Advantage and Part D Medical Loss Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model; Medicare Shared Savings Program Requirements; Corrections
- March 22, 2017
- https://www.gpo.gov/fdsys/pkg/FR-2017-03-22/pdf/2017-05675.pdf
Summary: Corrects technical errors in the addenda to the final rule published in the November 15, 2016, Federal Register.
CMS Voluntary Self-Referral Disclosure Protocol and Form
- Revision date March 27, 2017
- Use of the form is mandatory effective June 1, 2017. Parties submitting self-disclosures to the SRDP are encouraged, but not required, to use the SRDP Form now.
- https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/Self_Referral_Disclosure_Protocol.html
Summary: New protocol and form to self-disclose actual or potential violations of the physician self-referral statute and/or noncompliant financial relationships with physician(s).
Renewal of Advance Beneficiary Notice of Non-coverage, Form CMS-R-131
- March 28, 2017
- Effective Date for use of this ABN form is June 21, 2017
- https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html
Summary: The ABN form and instructions have been approved by the Office of Management and Budget (OMB) for renewal. While there are no changes to the form itself, providers should take note of the newly incorporated expiration date on the form. With the 2016 PRA submission, a non-substantive change has been made to the ABN. In accordance with Section 504 of the Rehabilitation Act of 1973 (Section 504), the form has been revised to include language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed.
Clinical Laboratory Data Reporting: Enforcement Discretion
- March 30, 2017
- https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/2017-March-Announcement.pdf
Summary: CMS will exercise enforcement discretion until May 30, 2017, regarding the data-reporting period for reporting applicable information under the Clinical Laboratory Fee Schedule and the application of the Secretary’s potential assessment of civil monetary penalties for failure to report applicable information. This discretion applies to entities that are subject to the data reporting requirements adopted in the Medicare Clinical Diagnostic Laboratory Tests Payment System final rule published on June 23, 2016 (81 FR 41036).
Decision Memo for Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Oxygen) (CAG-00060R)
Summary: Decision memo for HBO therapy that removes the coverage exclusion of Continuous Diffusion of Oxygen Therapy (CDO) from NCD Manual 20.29, Section C. CMS has decided that no National Coverage Determination is appropriate at this time concerning the use of topical oxygen for the treatment of chronic wounds and will amend NCD 20.29 by removing Section C, Topical Application of Oxygen. Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by the local contractors.
New Mailbox for BNI Notices Questions
- Effective April 13, 2017
Questions regarding any of the Fee For Service Beneficiary Notice Initiative (BNI) notices may be sent to the new mailbox: BNImailbox@cms.hhs.gov.
The BNI notices are:
- FFS Advance Beneficiary Notice of Non-coverage (FFS ABN)
- FFS Home Health Change of Care Notice (FFS HHCCN)
- FFS Skilled Nursing Facility Advance Beneficiary Notice (FFS SNFABN) and SNF Denial Letters
- FFS Hospital-Issued Notices of Non-coverage (FFS HINNs)
- FFS Expedited Determination Notices for Home Health Agencies, Skilled Nursing Facility, Hospice and Comprehensive Outpatient Rehabilitation Facility (FFS Expedited Determination Notices)
- Important Message from Medicare (IM) and Detailed Notice of Discharge (DND) (Hospital Discharge Appeal Notices)
- FFS Notice of Exclusion from Medicare Benefits - Skilled Nursing Facility (FFS NEMB SNF)
There is an exception for the Medicare Outpatient Observation Notice (MOON). Continue to send questions regarding the MOON to MOONMailbox@cms.hhs.gov.
Fiscal Year (FY) 2018 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) Prospective Payment System Proposed Rule
- April 14, 2017
- Fact Sheet - https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-04-14.html
Summary: Updates 2018 Medicare payment and polices when patients are admitted into hospitals. The rule updates payment rates, quality initiatives, and code sets. In addition to the payment and policy proposals, CMS is soliciting ideas for regulatory, sub-regulatory, policy, practice and procedural changes to improve the health care delivery system, make it less bureaucratic and complex, and reduce burden for clinicians, providers and patients in a way that increases quality of care and decreases costs.
In our modern texting, emailing, and messaging world, numerous acronyms have become common in order to allow us to communicate faster. One example is “LOL” which in texting lingo means “laugh out loud.” But to a Medicare patient or provider, LOL can mean “limitation on liability.” Limitation on Liability is one of the Financial Liability Protection provisions of the Social Security Act which protects beneficiaries, health care providers and suppliers under certain circumstances from unexpected liability for charges associated with claims that Medicare does not pay. Specifically, the LOL protections apply only when a provider believes that a Medicare covered item or service may be denied in a particular instance because it is not reasonable and necessary under §1862(a)(1) of the Act or because the item or service constitutes custodial care under §1862(a)(9) of the Act. If a provider believes a service will not be covered by Medicare because it is not medically necessary, they must give advance notice to the patient in order to shift the financial costs to the patient.
The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is a form given to Fee-for-Service Medicare beneficiaries in situations where Medicare payment is expected to be denied. There are no substantive changes to the form for the latest approval but there is a new expiration date and the form has been revised to include language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed. The effective date for use of this ABN form is 6/21/2017.
As a reminder, hospitals may issue an ABN for services that are not medically necessary, for therapy services that exceed the therapy cap amount and do not qualify for an exception, for experimental/investigational services, and since 2011 for preventive services when frequency limitations are exceeded. An ABN is mandatory in order to shift liability to the patient for these types of services. ABNs may also be used voluntarily for services that are not a Medicare benefit or are excluded from coverage. The ABN form is also used in certain situations by suppliers, physicians, hospices, home health agencies, CORFs, and SNFs (Part B only).
An ABN may be issued at the initiation of a service such as the beginning of a new patient encounter, start of a plan of care, or beginning of treatment - for example, diagnostic tests that are not medically necessary such as laboratory tests. A notice can also be given when services are reduced or terminated. Examples of this would be when a patient’s progression in rehabilitative therapy supports fewer visits per week but the patient wants to continue at the same frequency or when therapy services are no longer medically necessary but the patient wishes to continue.
Medicare has a number of resources with information about the Advance Beneficiary Notice.
- Medicare Claims Processing Manual, Chapter 30, Section 40.3
- MLN Booklet – Medicare Advance Beneficiary Notices
- ABN Form Instructions
- Medicare FFS ABN webpage with links to the ABN form (English and Spanish)
So be prepared to use the new ABN form in June; you wouldn’t want anyone to laugh at you for using the wrong form – LOL!
Debbie Rubio
TRANSMITTALS
Gender Dysphoria and Gender Reassignment Surgery
- MLN Matters® Number: MM9981
- Related Change Request (CR) #: CR 9981
- Related CR Release Date: March 3, 2017
- Effective Date: August 30, 2016
- Related CR Transmittal #: R194NCD
- Implementation Date: April 4, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9981.pdf
- Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.
Summary: Coverage determinations for gender reassignment surgery will continue to be made by the local MACs on a case-by-case basis.
April 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.1
- MLN Matters® Number: MM10002
- Related Change Request (CR) #: CR 10002
- Related CR Release Date: March 10, 2017
- Effective Date: April 1, 2017
- Related CR Transmittal #: R3735CP
- Implementation Date: April 3, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10002.pdf
- Affects providers who submit institutional claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH+H) MACs for services provided to Medicare beneficiaries.
Summary: Instructions and specifications for the Integrated Outpatient Code Editor (I/OCE) used for Outpatient Prospective Payment System (OPPS) and non-OPPS claims.
Clarification of Admission Order and Medical Review Requirements
- MLN Matters® Number: MM9979
- Related Change Request (CR) #: CR 9979
- Related CR Release Date: March 10, 2017
- Effective Date: January 1, 2016
- Related CR Transmittal #: R234BP
- Implementation Date: June 12, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9979.pdf
- Affects physicians submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.
Summary: Clarifies the rulemaking language of the Centers for Medicare & Medicaid Services (CMS) as it relates to “Admission and Medical Review Criteria for Hospital Inpatient Services Under Medicare Part A; Requirements for Physician Orders.”
Billing for Advance Care Planning (ACP) Claims
- MLN Matters® Number: MM10000
- Related Change Request (CR) #: CR 10000
- Related CR Release Date: May 17, 2017
- Effective Date: January 1, 2016
- Related CR Transmittal #: R3739CP
- Implementation Date: June 19, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10000.pdf
- Affects providers who submit claims to Medicare Administrative Contractors (MACs) for Advance Care Planning (ACP) services provided as an optional element of the Annual Wellness Visit (AWV) to Medicare beneficiaries.
Summary: Provides billing instructions for ACP when furnished as an optional element of an AWV. CMS has made the CPT code 99497 (Advance care planning) separately payable for Medicare OPPS claims when the service meets the criteria for separate payment under OPPS.
April 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- MLN Matters® Number: MM 10005
- Related Change Request (CR) #: CR 10005
- Related CR Release Date: March 3, 2017
- Effective Date: April 1, 2017
- Related CR Transmittal #: R3728CP
- Implementation Date: April 3, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10005.pdf
- Affects providers and suppliers who submit claims to Medicare Administrative Contractors (MAC), including Home Health and Hospice (HH&H) MACs, for services provided to Medicare beneficiaries paid under the Outpatient Prospective Payment System (OPPS).
Summary: Describes changes to and billing instructions for various payment policies implemented in the April 2017 OPPS update.
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2017
- MLN Matters Number: MM10036
- Related CR Release Date: March 17, 2017
- Related CR Transmittal Number: R3738CP
- Related Change Request (CR) Number: CR10036
- Effective Date: October 1, 2016
- Implementation Date: July 3, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10036.pdf
- Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Summary: Announces the changes that will be included in the July 2017 quarterly release of the edit module for clinical diagnostic laboratory services. This is a Recurring Update Notification that applies to Chapter 16, Section 120.2, of the ʺMedicare Claims Processing Manual.”
Clarification of Patient Discharge Status Codes and Hospital Transfer Policies
- SE0801 Rescinded March 15, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf
Summary: This article was rescinded on March 15, 2017. Information on the inpatient transfer policy is located in the "Medicare Claims Processing Manual" (100-04), Chapter 3. For questions concerning clarification on the proper usage of patient discharge status codes, providers should be utilizing the "UB-04 Manual" which is maintained by the National Uniform Billing Committee.
OTHER MEDICARE ANNOUNCEMENTS
Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model; Delay of Effective Date
- Interim final rule with comment period; delay of effective date
- https://www.gpo.gov/fdsys/pkg/FR-2017-03-21/pdf/2017-05692.pdf
Summary: This interim final rule with comment period (IFC) further delays the effective date of the final rule entitled ‘‘Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model’’ from March 21, 2017 until May 20, 2017. This IFC also delays the applicability date of the regulations at 42 CFR part 512 from July 1, 2017 to October 1, 2017 and effective date of the specific CJR regulations itemized in the DATES section from July 1, 2017 to October 1, 2017. We seek comment on the appropriateness of this delay, as well as a further applicability date delay until January 1, 2018.
Proposed Decision Memo for Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) (CAG-00449N)
Summary: CMS) proposes that the evidence is sufficient to cover supervised exercise therapy (SET) for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic peripheral artery disease (PAD).
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