Knowledge Base Category -
MEDICARE TRANSMITTALS – RECURRING UPDATES
Calendar Year (CY) 2020 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Provider Type Affected: Clinical Diagnostic Labs
Provider Action Needed: Change Request (CR) 11598 provides instructions for CY 2020, mapping for new codes, and updates for lab costs subject to reasonable charge payment.
MLN Article MM11598: https://www.cms.gov/files/document/mm11598.pdf
January 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
Provider Type Affected: ASCs billing Medicare Administrative Contractors
Provider Action Needed: CR 11607 informs MACs about updates to the ASC payment system for Calendar Year (CY) 2019 and describes changes to and billing instructions for various payment policies in the January 2020 ASC payment system update. This notification also includes updates to the HCPCS. Be sure your billing staffs are aware of these changes.
MLN Article MM11607: https://www.cms.gov/files/document/MM11607.pdf
January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0
Provider Type(s) Affected: Hospitals, Other Providers and Suppliers Billing MACs
What You Need to Know: This article is based on CR 11564, informs MACs, including Home Health MACs, and the Fiscal Intermediary Shared System (FISS) that the I/OCE is being updated for January 1, 2010.
MLN Article MM11564: https://www.cms.gov/files/document/mm11564.pdf
Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens
What You Need to Know: This Change Request (CR) revises the payment of travel allowances when billed on a per mileage basis using Health Care Common Procedure Coding System (HCPCS) code P9603 and when billed on a flat rate basis using HCPCS code P9604 for calendar year 2020.
MLN Article MM11641: https://www.cms.gov/files/document/mm11641.pdf
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.1, Effective Date: April 1, 2020
MLN Article MM11628: https://www.cms.gov/files/document/mm11628.pdf
OTHER MEDICARE TRANSMITTALS
Internet Only Manual Update to Pub 100-04, Chapter 16, Section 40.8 – Laboratory date of Service Policy
Provider Type Affected: Laboratories & other providers
What You Need to Know: In response to comments, CMS finalized excluding blood banks or centers from the laboratory DOS exception at 42 CFR 414.510(b)(5) in the CY 2020 OPPS/ASC final rule published on November 12, 2019. CMS also adopted a definition of “blood bank or center” and clarified that this policy change categorically excludes molecular pathology testing performed by laboratories that are blood banks or blood centers from the laboratory DOS exception at 42 CFR 414.510(b)(5).
MLN Article MM11574: https://www.cms.gov/files/document/mm11574.pdf
Revised Medicare Transmittals
January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Transmittal 266 replaces transmittal 264 released on December 20, 2019. Corrections made include:
- Section 5: change “removing 12 procedures from IPO list” to “removing 11 procedures from IPO list”
- Add a new section, number 18, “Correction of deductible and Coinsurance for HCPCS code, G0404,” and
- Change section 18 “Coverage Determinations” to section 19.
MLN Matters Article MM11605: https://www.cms.gov/files/document/mm11605.pdf
MEDICARE SPECIAL MLN & SPECIAL EDITION ARTICLES
SE18006 Reissued: New Medicare Beneficiary Identifier (MBI) Get It, Use It
On January 2, 2020 to update language reflected the use of the MBI number is fully implemented.
SE19006 Revised: Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System
Article Release Date: January 8, 2020
The Data Reporting Period has been delayed one year and as such all references to the 2020 data reporting period have been changed to 2021.
SE20002: Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Approval of Using the K3 Segment for Institutional Claims
Article Release Date: January 10, 2020
Provider Action Needed: This article provides guidance for processing claims for certain institutional claims that are subject to the Appropriate Use Criteria (AUC) program for advanced diagnostic imaging services. The CMS will begin to accept claims with this information as of January 1, 2020. This SE article contains an attached advanced diagnostic imaging UB-04 claim examples to help better understand the claims-based reporting concept of the AUC program.
https://www.cms.gov/files/document/se20002.pdf
MEDICARE EDUCATIONAL RESOURCES
January 2020 MLN Catalog
2020 marks the Medicare Learning Network’s® (MLN’s) 20th anniversary and the January 2020 Edition of the MLN Catalog is now available. Resources you will find in the catalog:
- MLN Matters® Articles
- Publications and Educational Tools
- MLN Connects® Newsletter
- Web-based Training Courses, and
- Provider Association Partnerships.
Billing Correctly for Polysomnography
The January 16, 2020 edition of MLN Connects provided Polysomnography Compliance Information, noting in a recent report, the Office of Inspector General (OIG) determined that CMS improperly paid practitioners for some claims associated with polysomnography services that did not meet Medicare requirements. We revised the Provider Compliance Tips for Polysomnography (Sleep Studies) (PDF) Fact Sheet to help you bill correctly. Additional resources:
- Medicare Claims Processing Manual, Chapter 15 (PDF) , Section 70
- Questionable Billing for Polysomnography Services OIG Report
- Medicare Payments to Providers for Polysomnography Services Did Not Always Meet Medicare Billing Requirements OIG Report
OTHER MEDICARE UPDATES
2020 OPPS Correction Notice
On January 3, 2020, CMS published a correction notice in the Federal Register. This document corrects technical errors that appeared in the final rule that appeared in the November 12, 2019 issue of the Federal Register. Included in the notice is the inadvertent omission of two additional botulinum toxin injection codes J0586 and J0588 that have now been added to the codes in Table 65 – Final List of Outpatient Services That Require Prior Authorization.
You can read more about the new Prior Authorization requirement in a related MMP article at http://www.mmplusinc.com/news-articles/item/2020-opps-final-rule-supervision-of-therapeutic-services-and-prior-authorizations.
Palmetto GBA Jurisdiction J Medicare Advantage (MA) Plan Overpayments Update
On January 3, 2020, Phase III Settlement Offer Letters were mailed to affected providers. The settlement offer is intended to address all remaining unresolved “MA overpayment” claims.
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"AZ9J8M2780?opendocument
New Important Message from Medicare (IM) and Detailed Notice of Discharge
The Office of Management and Budget (OMB) has renewed the IM (CMS-10065) and DND (CMS-10066). The revised IM has a new CMS Form number (CMS-10065). It was formerly CMS-R-193. Hospitals are required to use the new forms as of April 1, 2020. Until then the previous and new versions are acceptable for use. You can access the forms at the following links:
- https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/Important-Message-English-and-Spanish.zip
- https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/Detailed-Notice-English-and-Spanish.zip
New Medicare Outpatient Observation Notice (MOON)
The OMB has renewed the MOON (CMS-10611). The only change made was the expiration date is now 12/31/2022. Similar to the IM and DND, hospitals are required to use the new MOON beginning April 1, 2020. Both previous and new versions are acceptable for use through March 31, 2020. You can access the MOON at the following link:
January 13, 2020 Memorandum: Informational Notice: Forthcoming Integration of the Psychiatric Hospital Program into the Hospital Program and State Operations Manual (SOM) Changes
Aims of Memorandum:
- To improve the identification of quality issues, the CMS is in the process of integrating the psychiatric hospital program survey into the hospital program survey,
- Update and relocation of the Interpretive Guidelines for Psychiatric Hospitals, and
- Develop training to provide the necessary competencies for all State Survey Agency surveyors to evaluate compliance with the psychiatric hospital CoPs.
Link to Memorandum: https://www.cms.gov/files/document/admin-info-20-05-hospitalpsych.pdf
Link to Related CMS Newsroom Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cms-reduces-psychiatric-hospital-burden-new-survey-process
2020 Updates to OIG Work Plan
OIG updates this dynamic, web-based Work Plan monthly to ensure that it more closely aligns with the work planning process. The monthly update includes the addition of newly initiated Work Plan items, which can be found on the Recently Added Items page. Beginning in January 2020, completed Work Plan items will remain in the active Work Plan for one month, after which they will be moved into the Archive. Recently completed reports can be found on OIG's What's New page. This web-based Work Plan will evolve as OIG continues to pursue complete, accurate, and timely public updates regarding our planned, ongoing, and published work.
January 2020 Medicare Quarterly Provider Compliance Newsletter
The January 2020 edition of this newsletter includes CERT review findings specific to the provision of Lumbar Sacral Orthosis (LSO) and Recovery Auditor findings from a review of Trastuzumab (Herceptin), J9355.
MEDICARE TRANSMITTALS – RECURRING UPDATES
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.0, Effective January 1, 2020
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)--April 2020 Update
A maintenance update of ICD-10 conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
2020 Annual Update to the Therapy Code List
Updates the list of codes that sometimes or always describe therapy services.
2020 Annual Update of Per-Beneficiary Threshold Amounts
Updates the annual per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for CY 2020.
Claim Status Category and Claim Status Codes Update
https://www.cms.gov/files/document/mm11467
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
https://www.cms.gov/files/document/mm11489
Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year (CY) 2020
https://www.cms.gov/files/document/MM11542
OTHER MEDICARE TRANSMITTALS
Addition of Medical Severity Diagnosis Related Groups (MS-DRG) Subject to Inpatient Prospective Payment System (IPPS) Replaced Devices Offered Without Cost or With a Credit Policy
Medicare Severity Diagnosis-Related Groups (MS-DRGs) 319 and 320 (Other Endovascular Cardiac Valve Procedures with and without major complications and comorbidities (MCC), respectively) added to the list of MS-DRGs subject to the policy for replaced devices offered without cost or with a credit.
Medicare Physician Fee Schedule Database (MPFSDB) Update to Status Indicators
Status Indicator Q (therapy functional information code) is no longer effective with the 2020 MPFSDB beginning January 1, 2020. Medicare no longer requires functional therapy reporting.
Positron Emission Tomography (PET) Scan - Allow Tracer Codes Q9982 and Q9983 in the Fiscal Intermediary Shared System (FISS)
Currently, the system does not recognize HCPCS Q9982 and Q9983 as valid radiopharmaceutical tracer codes and claims are incorrectly returned to the provider as unprocessed or rejected.
Updating FISS Editing for Practice Locations to Bypass Mobile Facility and/or Portable Units and Services Rendered in the Patient's Home
Implements the newly approved National Uniform Billing Committee (NUBC) Condition Code “A7” and improved edit criteria in Medicare systems to bypass edits that match service facility location on certain hospital claims.
https://www.cms.gov/files/document/mm11470
Summary of Policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List
A summary of the policies in the CY 2020 MPFS Final Rule, announces the Telehealth Originating Site Facility Fee payment amount and makes other policy changes related to Medicare Part B payment.
https://www.cms.gov/files/document/mm11560
Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and Coding Requirements
Updates language pertaining to the National Correct Coding Initiative (NCCI).
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4465CP.pdf
Update to Medicare Claims Processing Manual, Chapters 1, 23 and 35
New Global Billing and Separate TC/PC billing instructions. For both paper and electronic claims, when a global diagnostic service code is billed (for example, no modifier TC and no modifier -26), the address where the TC was performed must be reported on the claim.
https://www.cms.gov/files/document/mm10882
REVISED MEDICARE TRANSMITTALS
April 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Revision - Reference added to a related article SE19009 which replaces Section 6 - Chimeric Antigen Receptor (CAR) T- Cell Therapy - instructions on pages 5-7 of this article.
Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System
Revision - Updates and clarifies information regarding the eMDR registration/enrollment to indicate the provider and the HIH roles with more detail.
Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements
Revision - Removes codes that are not available for 2020.
MEDICARE COVERAGE UPDATES
Proposed Decision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer
Expands coverage of Next Generation Sequencing (NGS) as a diagnostic laboratory test when performed in a CLIA-certified laboratory, when ordered by a treating physician and when specified requirements are met.
MEDICARE PRESS RELEASES AND FACT SHEETS
CMS Hospital Value-Based Purchasing Program Results for Fiscal Year 2020
The Hospital VBP Program works by adjusting what Medicare pays hospitals under the Inpatient Prospective Payment System (IPPS) based on the quality and cost of inpatient care the hospitals provide to patients.
MEDICARE EDUCATIONAL RESOURCES
Palmetto GBA 2020 Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) Teleconference Schedule
Palmetto GBA will host a series of Medical Review Hot Topic Targeted Probe and Educate (TPE) Teleconferences in 2020.
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BGQT2X1030?opendocument
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Bill Correctly for Medicare Telehealth Services
OTHER MEDICARE UPDATES
Extension of Detailed Notice of Discharge Beyond Expiration Date
The currently available Detailed Notice of Discharge (hospital notice) has an expiration date of October 31, 2019. The current notice is covered under an extension and hospitals should continue using it until CMS publishes the updated notice.
https://www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices
2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule
This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for Calendar Year 2020.
https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-24138.pdf
2020 Medicare Physician Fee Schedule Final Rule
This major final rule addresses: changes to the physician fee schedule (PFS); other changes to Medicare Part B payment policies to ensure that payment systems are updated to reflect changes in medical practice, relative value of services, and changes in the statute; and other topics.
https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-24086.pdf
Patients over Paperwork Newsletter November 2019
Through “Patients over Paperwork,” CMS established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience.
https://www.cms.gov/files/document/november-2019-patients-over-paperwork-newsletter
KEPRO Case Review Connections Winter 2020 – Acute Care Edition
KEPRO is the Beneficiary and Family Centered Care QIO (BFCC-QIO) for 29 states. Case Review Connections is a quarterly newsletter that provides a glimpse into KEPRO and the services provided, along with success stories and updates from the Centers for Medicare & Medicaid Services (CMS).
https://keproqio.com/bene/newsletter/2020winteracute/
Hospital Price Transparency Requirements Final Rule
Establishes requirements for hospitals operating in the United States to establish, update, and make public a list of their standard charges for the items and services that they provide.
https://www.hhs.gov/sites/default/files/cms-1717-f2.pdf
Transparency in Coverage Proposed Rule
Sets forth proposed requirements for group health plans and health insurance issuers in the individual and group markets to disclose cost-sharing information upon request, to a participant, beneficiary, or enrollee (or his or her authorized representative), including an estimate of such individual’s cost-sharing liability for covered items or services furnished by a particular provider.
https://www.hhs.gov/sites/default/files/cms-9915-p.pdf
CY 2020 - Clinical Laboratory Fee Schedule Test Codes Final Determinations
In November of each year, CMS finalizes the basis of payment for new and substantially revised test codes and the amount of payment through the annual CMS instruction implementing the updated CLFS for the next CY.
Payment for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments
Revised Hospital Outpatient Prospective Payment System Pricer to update the rates being applied to claim lines for clinic visit services at excepted off-campus PBDs for 2019.
Extension of the MOON Beyond Expiration Date
The currently available Medicare Outpatient Observation Notice (MOON) has an expiration date of December 31, 2019. The currently available MOON is covered under an extension and hospitals should continue using the current notice until CMS publishes the updated notice.
https://www.cms.gov/Medicare/Medicare-General-Information/BNI/MOON
The holiday season is upon us and I hope that everyone had a Happy Thanksgiving. It is the time of year when certain things expand. If you believe the hype from Hallmark Christmas movies, our hearts expand with more kindness and joy at this time of year; our waistlines usually expand from all the holiday meals and sweet treats; and our Christmas list and associated budget seem to expand as it gets closer to Christmas (which reversely causes our wallets to shrink). Evidently, CMS thought it was a good time to expand on the requirements associated with hospital price transparency. They also gave an early Christmas present however by delaying the new requirements until January 1, 2021. This means for now and until January 2021, hospitals are to continue to comply with the existing guidance which requires hospitals to make public their chargemaster charges (gross charges) online in a machine-readable format.
As a reminder, this requirement comes from the Health Care and Education Reconciliation Act of 2010 that “requires each hospital operating in the United States for each year to establish (and update) and make public a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis related groups (DRGs)…” The 2019 Outpatient Prospective Payment System (OPPS) proposed and final rules updated guidelines to require hospitals to make available a list of their current standard charges via the Internet in machine-readable format and to update this information at least annually, or more often as appropriate. CMS further clarified in these rules that this requirement applies to all hospitals operating within the United States and to all items and services provided by the hospital. CMS’s reasoning for the requirements is that they believe there is a direct connection between hospital charge transparency and more affordable, lower cost healthcare.
The expansion of the requirements was originally discussed in the 2020 OPPS Proposed Rule and made final in a separate Final Rule for Price Transparency Requirements for Hospitals to Make Standard Charges Public. The new requirements are based on feedback from the 2019 revised guidelines and from an Executive Order on “Improving Price and Quality Transparency in American Healthcare to Put Patients First” (June 24, 2019). I refer readers to the actual rule for all the reasons CMS believes these new requirements are necessary. Below is a summary of what the new requirements are, including many new definitions for clarification. At the same time as the release of this final rule, CMS also released a proposed rule entitled Transparency in Coverage that would place complementary transparency requirements on most individual and group market health insurance issuers and group health plans.
“Hospital” Definition
The requirements apply to hospitals which are defined in the new Final Rule (FR) as all institutions recognized, licensed and/or approved as a hospital by State or applicable local laws. This includes:
- All Medicare-enrolled hospitals plus hospitals that do not participate in Medicare,
- Hospitals in all States, the District of Columbia, and US territories as listed in the FR (Puerto Rico, Virgin Islands, Guam, etc.),
- Critical access hospitals (CAHs), inpatient psychiatric facilities (IPFs), sole community hospitals (SCHs), and inpatient rehabilitation facilities (IRFs),
- Each hospital location operating under a single license or approval that has a different set of standard charges, such as a hospital outpatient department located at an off-campus location.
It does not include entities such as ambulatory surgical centers (ASCs) or other non-hospital sites-of-care from which consumers may seek healthcare items or services, although CMS encourages such entities to make public their standard charges. It also does not apply to federally-owned or operated hospitals, such as Indian Health Service (IHS) facilities, Veterans (VA), and Department of Defense (DOD) hospitals because these hospitals generally do not provide services to the general public and their payment rates are not subject to negotiation.
“Items and Services” Definition
“Items and services” provided by the hospital are “all items and services, including individual items and services and service packages, that could be provided by a hospital to a patient in connection with an inpatient admission or an outpatient department visit for which the hospital has established a standard charge.” This includes:
- Supplies, procedures, room and board, facility use, and facility fees;
- Service packages which mean an aggregation of individual items and services into a single service with a single charge (such as DRG or APC charges);
- Services of employed physicians and non-physician practitioners; and
- Any other items or services for which a hospital has established a charge.
Disclaimer – Please do not shoot the messenger if some of the new requirements do not seem to make sense. CMS is convinced that hospitals routinely contract payer-specific rates for service packages. They also clarify that the word “charges” is equivalent to “payment rates” whether for an individual item/service or a service package.
“Standard Charges” Definition
This is the big definition that is significantly expanded from the current requirements. Under the new requirements the following are considered standard charges and must be included in both the Internet-posted machine-readable format and shoppable services postings (discussed in more detail below) when the new requirements become effective in 2021.
- Gross charges – charges as recorded in the chargemaster, absent any discounts.
- Payer-specific negotiated charges – charges the hospital has negotiated with a third party payer for an item or service.
- “Third party payer” is “an entity that, by statute, contract, or agreement, is legally responsible for payment of a claim for a healthcare item or service.”
- Hospitals should display all negotiated charges, including, for example, charges negotiated with Medicare Advantage plans, Medicaid MCOs, and other Medicaid managed care plans.
- Payer-specific negotiated charges would not include non-negotiated payment rates (such as those payment rates for FFS Medicare or Medicaid).
- CMS states that hospital payer-specific negotiated charges or rates can be found within the in-network contracts that hospitals have signed with third party payers. Per CMS, such contracts often include rates sheets that contain a list of hospital items and services (including service packages) and the corresponding negotiated rates. CMS recommends hospitals request an electronic copy of their contract and corresponding rate sheet from the third party payer if it is not already available in that format.
- Discounted Cash Price – the price the hospital would charge individuals who pay cash (or cash equivalent) for an individual item or service or service package.
- Groups that would benefit from knowing the discount cash price would be the uninsured and those who may have some healthcare coverage but who still bear the full cost of at least certain healthcare services.
- The “discounted cash price” would reflect the discounted rate published by the hospital, unrelated to any charity care or bill forgiveness that a hospital may choose or be required to apply to a particular individual’s bill.
- The discounted cash price may be generally analogous to the “walk-in” rate but would apply to all self-pay individuals, regardless of insurance status.
- For hospitals that have not determined a discounted cash price for self-pay consumers the hospital’s discounted cash price would simply be its gross charges as reflected in the chargemaster.
- De-identified Minimum Negotiated Charge – the lowest charge that a hospital has negotiated with all third party payers for an item or service.
- To determine the de-identified negotiated charges, hospitals consider the distribution of all negotiated charges across all third party payer plans and products for each hospital item or service and then selects the lowest and highest rates.
- The distribution would not include non-negotiated charges with third party payers
- The third party payer with which these rates are negotiated is not identified.
- De-identified Maximum Negotiated Charge - the highest charge that a hospital has negotiated with all third party payers for an item or service.
- Bullets for de-identified minimum negotiated charge listed above also apply to the de-identified maximum negotiated charge.
HOSPITALS MUST MAKE PUBLIC THEIR STANDARD CHARGES IN TWO WAYS:
- a comprehensive machine-readable file that makes public all standard charge information for all hospital items and services, and
- a consumer-friendly display of common “shoppable” services derived from the machine-readable file.
Comprehensive Machine-Readable File
- The machine-readable list of hospital items and services is required to include the following charges, as applicable, for each item and service: – the gross charge, the payer-specific negotiated charges, the discounted cash price, de-identified minimum negotiated charge, and de-identified maximum negotiated charge
- In addition to the above charges, the listing must include:
- A description of each item or service (including both individual items and services and service packages).
- Any code used by the hospital for purposes of accounting or billing for the item or service, including, but not limited to, the CPT code, HCPCS code, DRG, NDC, or other common payer identifier.
- Hospitals must post their standard charge information in a single digital file in a machine-readable format.
- A machine-readable format is a digital representation of data or information in a file that can be imported or read into a computer system for further processing.
- Examples of machine-readable formats include, but are not limited to, .XML, .JSON and .CSV formats.
- A PDF would not meet this definition because the data contained within the PDF file cannot be easily extracted without further processing or formatting.
- CMS requires that hospitals use a CMS-specified naming convention for the file (§ 180.50(d)(5)).
- The naming convention for the file must be:
<ein>_<hospital-name>_standardcharges.[json|xml|csv] - Hospitals have discretion to choose the Internet location they use to post their files as long as
- They are displayed on a publicly-available website,
- Are displayed prominently and
- Clearly identify the hospital location with which the standard charges information is associated
- The data must be easily accessible and without barriers, which means the data can be accessed free of charge, without having to establish a user account or password, and without having to submit personal identifiable information (PII)
- The data must be able to be digitally searched
- Files must be updated annually
- This means such updates must occur at least once in a 12-month period.
- Hospitals must clearly indicate the date of the last update to the standard charge data either within the file or otherwise clearly associated with the file.
- These requirements apply to each hospital location so that each location with separate charges makes a list public
Shoppable Services
A “shoppable service” is a service package that can be scheduled by a healthcare consumer in advance. Shoppable services are typically provided in non-urgent situations, which allows patients to price shop and schedule a service at a time that is convenient for them.
- Hospitals must make public the following prescribed standard charges for at least 300 shoppable services in a consumer-friendly manner.
- This includes 70 shoppable services specified by CMS that are provided by the hospital, plus as many additional shoppable services as would be necessary to reach a total of at least 300 shoppable services
- If a hospital does not provide some of the 70 CMS-specified services, then the hospital would identify enough shoppable services so that the total number of shoppable services is at least 300.
- Hospitals should select services based on the utilization or billing rate of the services in the past year. In other words, the shoppable services selected for display by the hospital should be commonly provided to the hospital’s patient population.
- If a hospital does not provide 300 shoppable services, the hospital must list as many shoppable services as they provide.
- The 70 CMS-specified shoppable services are found in Table 3of the FR and are divided into four broad categories: E&M Services, Laboratory and Pathology Services, Radiology Services, Medicine and Surgery Services.
- The hospital must display the following types of standard charges described above that apply to each shoppable service (and corresponding ancillary services, as applicable)– the payer-specific negotiated charges, the discounted cash price, de-identified minimum negotiated charge, and de-identified maximum negotiated charge.
- The shoppable services list must also include:
- A plain-language description of each shoppable service.
- An indicator when one or more of the CMS-specified shoppable services are not offered by the hospital.
- The location at which the shoppable service is provided, including whether the charges at that location apply to the inpatient setting, the outpatient department setting, or both.
- Any primary code used by the hospital for purposes of accounting or billing for the shoppable service, including, as applicable, the CPT code, the HCPCS code, the DRG, or other common service billing code.
- Hospitals may use, as applicable, an appropriate payer-specific billing code (for example, an APR-DRG code) in place of the MS-DRG code indicated for the five procedures in the list of 70 CMS-specified shoppable services that are identified by MS-DRG codes 216, 460, 470, 473, and 743.
- When the shoppable service is customarily accompanied by the provision of ancillary services, the hospital must present the shoppable service as a grouping of related services, meaning that the charge for the primary shoppable service (whether an individual item or service or service package) is displayed along with charges for ancillary services.
- An “ancillary service” is an item or service a hospital customarily provides as part of or in conjunction with a shoppable primary service.
- Ancillary items and services may include laboratory, radiology, drugs, delivery room (including maternity labor room), operating room (including post-anesthesia and postoperative recovery rooms), therapy services (physical, speech, occupational), hospital fees, room and board charges, and charges for employed professional services.
- They may also include additional services that are provided by the hospital, for example, local and/or global anesthesia, services of employed professionals, supplies, facility and/or ancillary facility fees, imaging services, lab services, and pre- and post-op follow up.
- A hospital must select an appropriate publicly available Internet location for purposes of making public the standard charge information for shoppable services in a consumer-friendly format.
- The information must be displayed in a prominent manner that identifies the hospital location with which the standard charge information is associated.
- The shoppable services information must be easily accessible, without barriers, including, but not limited to, ensuring the information is: (i) free of charge; (ii) accessible without having to register or establish a user account or password; (iii) accessible without having to submit PII; (iv) searchable by service description, billing code, and payer.
- Standard charge information must be updated at least once annually and the date must be indicated with the information.
- CMS did not finalize the requirement to provide a paper copy of information on consumer-friendly shoppable services.
Price Transparency Tool
CMS encourages, but does not require, that hospitals develop a price comparison tool to make standard charges available in a machine-readable format to third-party tool developers as well as the general public. They also determined that having a price transparency tool might meet the price transparency requirements for shoppable services.
“A hospital that maintains an Internet-based price estimator that meets certain criteria is deemed to have met our requirements at 45 CFR 180.60. The price estimator tool must:
- Allow healthcare consumers to, at the time they use the tool, obtain an estimate of the amount they will be obligated to pay the hospital for the shoppable service.
- Provide estimates for as many of the 70 CMS-specified shoppable services that are provided by the hospital, and as many additional hospital-selected shoppable services as is necessary for a combined total of at least 300 shoppable services.
- Is prominently displayed on the hospital’s website and be accessible without charge and without having to register or establish a user account or password.”
Like our hearts, waistlines, and these price transparency requirements, the length of my article has expanded beyond what I originally planned. I think that is enough information for this week’s article. Next week, I will address CMS’s plans for monitoring, penalties, and appeals.
Debbie Rubio
Last week’s Wednesday@One included a lengthy article about the requirements for hospitals to make public their standard charges, including payer-negotiated charges as described in the Final Rule for Price Transparency Requirements for Hospitals to Make Standard Charges Public. The only piece of good news from that Rule was the delay in implementation of the new requirements until January 1, 2021. Until then, hospitals still have to comply with the existing guidance which requires hospitals to make public their chargemaster charges (gross charges) online in a machine-readable format.
If you read last week’s article, you know that complying with the new price transparency rule will be quite a challenge – that is, if the legality of the new requirements holds up. There are already lawsuits challenging the new requirements, especially concerning the release of payer-negotiated rates. Being ever optimistic, CMS included in the final rule how they plan to oversight compliance and what will happen should a provider be found in noncompliance.
Monitoring
For monitoring compliance with the new price transparency requirements, CMS plans to rely predominately on complaints from individuals or entities regarding a hospital’s potential noncompliance.
Monitoring methods may include, but are not limited to, the following, as appropriate:
- CMS’ evaluation of complaints made by individuals or entities to CMS.
- CMS review of individuals’ or entities’ analysis of noncompliance.
- CMS audit of hospitals’ websites.
CMS will be reviewing and auditing to determine if a hospital’s noncompliance constitutes a material violation of one or more requirements. This may include, but is not limited to, failure to make public its standard charges as required or failure to make public its standard charges in the form and manner required.
Actions to Address Noncompliance
CMS may take the following actions if they determine the hospital is noncompliant with the price transparency requirements:
- Provide a written warning notice to the hospital of the specific violation(s) - (notice of violation).
- Request a Corrective Action Plan (CAP) from the hospital if its noncompliance constitutes a material violation of one or more requirements.
- The CAP must be in the form and manner, and submitted by the deadline, specified in the notice of violation issued by CMS to the hospital.
- The CAP must specify the corrective actions or processes the hospital will take to address the deficiencies identified and the timeframe for completion.
- A CAP is subject to CMS review and approval.
- Hospitals must comply with the requirements of the CAP.
- CMS may monitor and evaluate the hospital’s compliance with the CAP.
Penalties
CMS may impose a civil monetary penalty (CMP) on the hospital and publicize the penalty on a CMS website if:
- A hospital fails to submit a CAP in the form, manner, or by the deadline, specified in a notice of violation or
- The hospital fails to correct violation(s) within the specified timeframes of the CAP.
The maximum daily dollar amount for a CMP to which a hospital may be subject is $300, even if the hospital is in violation of multiple discrete requirements of 45 CFR, part 180.
CMS will provide a written notice of imposition of a CMP to the hospital via a certified/traceable delivery. The notice will contain the following elements:
- The basis for the hospital’s noncompliance – that is, the requirement(s) the hospital violated, and the hospital’s failure to submit and/or comply with a requested CAP.
- The effective date of the violation as determined by CMS.
- The amount of the penalty as of the date of the notice.
- Payment instructions. The payment must be made in full within 60 calendar days after the date of the notice of imposition of a CMP from CMS or within 60 calendar days after the date of a final and binding appeal decision to uphold, in whole or in part, the CMP.
- Intent to post the notice of imposition of a CMP on a CMS website.
- Statements that:
- penalties may continue to be imposed for continuing violations,
- the hospital has a right to a hearing, and
- if the hospital fails to request a hearing within 30 calendar days, the penalty and subsequent penalties will be imposed without right of appeal.
CMS can issue additional notices either subsequently for continuing justification or as a “clarifying modification” to conform to adjudicated finding when an appealed “CMP is upheld, in part, by a final and binding decision.”
CMS will post notices of all CMPs, initial and subsequent, on a CMS website. This website will also include posting that the CMP is under review, while they review the hospital’s request for a hearing (appeal). This posting will be maintained or removed based on the outcome of the appeal.
Appeals
“A hospital upon which CMS has imposed a penalty under 45 CFR part 180 may appeal that penalty in accordance with 45 CFR part 150, subpart D, with the exceptions (for the propose of applying the provisions of part 150 to CMPs under part 180) as described in this section of this final rule.”
Generally, under this approach, a hospital upon which CMS has imposed a penalty may request a hearing before an Administrative Law Judge (ALJ) of that penalty. The Administrator of CMS, at his or her discretion, may review in whole or in part the ALJ’s decision. A hospital against which a final order imposing a CMP is entered may obtain judicial review.
If the hospital does not request a hearing within 30 calendar days, CMS may impose the original CMP and additional penalties due to continuing violations without further right of appeal for the hospital. The only exception to this is if the hospital can show good cause as to why they did not request a hearing within the time limits (30 days).
Monitoring through complaints, a limit of $300 per day fine, and an ALJ appeal process may not seem to reflect the highest priority for the price transparency initiative. Some commentaries say this rule and the proposed rule relating to price transparency for health insurers and health plans, especially the parts being challenged in court, may be politically motivated since it is an election year. Monitoring complaints sounds simple but, I think it could be effective for CMS and scary for hospitals. If you fail to follow the rules, one disgruntled patient or employee who hears about these requirements could go looking for your charges and report your noncompliance to CMS. And I would not be surprised to have some watchdog group or the press scrutinizing hospital websites also.
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
2020 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
Annual Clotting Factor Furnishing Fee Update 2020
The clotting factor furnishing fee for 2020 is $0.226 per unit.
Influenza Vaccine Payment Allowances - Annual Update for 2019-2020 Season
October 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.3
October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Includes numerous new and revised codes.
October Quarterly Update for 2019 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update
OTHER MEDICARE TRANSMITTALS
Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System – REVISED
Article revised on August 26, 2019, to reflect changes made to the eMDR registration screens within NPPES. The article includes illustrations of the new screens that providers will have to complete in order to register to receive the eMDRs.
Implementation of the Award for the Jurisdiction H Part A and Part B Medicare Administrative Contractor (JH A/B MAC)
Announces the Jurisdiction JH A/B MAC re-competition procurement that was recently awarded to Novitas Solutions, Inc., the incumbent contractor for this workload.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2358OTN.pdf
Billing for Hospital Part B Inpatient Services
Reminder of the policy regarding billing instructions for hospital Part B inpatient service claims, including the allowance of Revenue Code 0240 on 012x Type of Bills (TOB).
MEDICARE SPECIAL EDITION ARTICLES
Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System – REVISED
Revised on September 5, 2019, to delete incorrect information in the section titled Only Applicable Information Attributed to non-Hospital Patients is Reported.
Activation of Systematic Validation Edits for OPPSProviders with Multiple Service Locations – Update – REVISED
Revised on September 5, 2019, to announce a delay of full implementation until April 2020.
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
OTHER MEDICARE UPDATES
Case Review Connections, Fall 2019
KEPRO Quarterly Acute Care Newsletter
MEDICARE TRANSMITTALS – RECURRING UPDATES
Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Quarterly update.
October Quarterly Update to 2019 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement
Updates the lists of HCPCS codes that are subject to the consolidated billing provision of the SNF Prospective Payment System (PPS).
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2020
Changes from IPF Final Rule applicable to discharges occurring from October 1, 2019, through September 30, 2020 (FY 2020).
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2020 Update
Relevant NCD coding changes for:
- NCD20.7 Percutaneous Transluminal Angioplasty
- NCD110.18 Aprepitant
- NCD110.23 Stem Cell Transplantation
- NCD150.3 Bone Mineral Density Studies
- NCD220.4 Mammography
- NCD220.13 Percutaneous Image-Guided Breast Biopsy
- NCD270.3 Blood Derived-Products for Chronic, Non-Healing Wounds
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update
Claim Status Category and Claim Status Codes Update
Healthcare Provider Taxonomy Codes (HPTCs) October 2019 Code set Update
OTHER MEDICARE TRANSMITTALS
Documentation of Medical Necessity of the Home Visit; and Physician Management Associated with Superficial Radiation Treatment - REVISED
Removes the requirement that the medical record show a home visit was medically necessary instead of an office or outpatient visit and allows billing E/M codes (99211, 99212, and 99213) for levels I through III with modifier 25 when performed for the purpose of reporting physician work associated with radiation therapy planning, radiation treatment device construction, and radiation treatment management when performed on the same date of service as superficial radiation treatment delivery.
Oxygen Policy Update
Implements a new policy and coding for oxygen content.
Instructions for Use of Informational Remittance Advice Remark Code Alert on Laboratory Service Remittance Advices
To assist in reminding laboratories of their reporting obligations, the following new alert RARC code will appear on remittances:
- N817: ALERT-Applicable laboratories are required to collect and report private payor data and report that data to CMS between January 1, 2020 - March 31, 2020
Bypassing Payment Window Edits for Donor Post-Kidney Transplant Complication Services
Manual Update to Sections 1.2 and 10.2.1 in Chapter 18 of the Medicare Claims Processing Manual
Adds a link to the current influenza codes and payment rates.
MEDICARE SPECIAL EDITION ARTICLES
Medicare Coverable Services for Integrative and Non-pharmacological Chronic Pain Management
Given the issues associated with using opioids for acute and chronic pain, this article summarizes some other treatment options to consider when you treat Medicare patients for chronic pain.
New Medicare Beneficiary Identifier (MBI) Get It, Use It – REISSUED
Use MBIs now for all Medicare transactions.
New Documentation Requirements for Filing Medicare Cost Reports
The FY 2019 Medicare IPPS final rule changed the required supporting documentation that providers must submit with the Medicare cost report.
MEDICARE COVERAGE UPDATES
Decision Memo for Chimeric Antigen Receptor (CAR) T-cell Therapy for Cancers (CAG-00451N)
Posted final decision memo.
https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=291
Medicare Press Releases
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Ambulance Fee Schedule and Medicare Transports
- Skilled Nursing Facility 3-Day Rule Billing
Skilled Nursing Facility 3-Day Rule Billing
MLN Fact Sheet
Ambulance Fee Schedule and Medicare Transports Booklet
MLN Booklet
OTHER MEDICARE UPDATES
FY 2020 Coding Updates
ICD-10-CM Coding Guidelines - https://www.cdc.gov/nchs/icd/icd10cm.htm
ICD-10-CM (Diagnosis Codes) - https://www.cms.gov/Medicare/Coding/ICD10/2020-ICD-10-CM.html
ICD-10-PCS (Procedure Codes) - https://www.cms.gov/Medicare/Coding/ICD10/2020-ICD-10-PCS.html
2020 Advance Beneficiary Notice (ABN) Forms
https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html
In the 2020 Outpatient Prospective Payment System (OPPS) Proposed Rule, CMS puts forth new proposed requirements for hospitals to make public a list of their standard charges. The basic requirement from the Public Health Services Act “requires each hospital operating within the United States for each year to establish (and update) and make public a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis-related groups.” The 2019 OPPS Final Rule required “hospitals to make available a list of their current standard charges via the Internet in a machine-readable format and to update this information at least annually, or more often as appropriate.”
I encourage those who will be dealing with the implementation of whatever requirements become final to read the proposed rule because understanding the reasoning and considerations behind the decisions is often beneficial. The discussion in the 2020 proposed rule includes the details and all the whys and wherefores of the proposals, but let’s start with some of the facts. The basics of the new proposal is an expansion of hospital charge display requirements to include charges and information based on negotiated rates and for common shoppable items and services, in a manner that is consumer-friendly.
Definitions
CMS includes numerous definitions throughout their discussion for additional clarity to the requirements. Some of these include:
- Hospital – an institution licensed as a hospital or approved as meeting licensing standards pursuant to State/local law.
- This includes critical access hospitals (CAHs), inpatient psychiatric facilities (IPFs), sole community hospitals (SCHs), and inpatient rehabilitation facilities (IRFs).
- It does not include entities such as ambulatory surgical centers (ASCs) or other non-hospital sites-of-care from which consumers may seek health care items and services. CMS encourages such sites to make their charges public, but it is not required.
- It also does not apply to federally-owned or operated hospitals, such as VA hospitals, because these facilities do not provide services to the general public and the established payment rates for services are not subject to negotiation.
- Items and Services – all items and services, including individual items and services and service packages, that could be provided by a hospital to a patient in connection with an inpatient admission or an outpatient department visit for which the hospital has established a standard charge.
- This includes supplies, procedures, room and board, use of the facility and other items (generally described as facility fees), services of employed physicians and non-physician practitioners (generally reflected as professional charges), and any other items or services for which a hospital has established a charge.
- It does not include physicians and nonphysician practitioners who are not employed by the hospital because they are practicing independently, establish their own charges for services, and receive the payment for their services.
- Chargemaster – the list of all individual items and services maintained by a hospital for which the hospital has established a standard charge.
- Standard charges mean “gross charges” and “payer-specific negotiated charges.”
- Gross charges are the charges for individual items or services that are reflected on a hospital’s chargemaster.
- A “payer-specific negotiated charge” is the charge the hospital has negotiated with a third-party payer for an item or service. Payer negotiated charges would include those charges negotiated with Medicare Advantage plans, but would not include Medicare Fee-for-Service rates since they are not negotiated.
Requirements for Standard Charges
The Proposed Rule is prescriptive about the type of information that should be displayed online in a single digital file that is machine readable to ensure uniformity.
- The file should include the item, service, or service package description; applicable codes, such as CPT, HCPCS, DRG, or NDC codes; revenue codes; the gross charge; and all payer-specific negotiated charges for that item/service linked with the name of the third-party payer.
- Examples of machine-readable formats include, but are not limited to, .XML, JSON and .CSV formats. A PDF is not an acceptable format.
- Hospitals can choose where to post the file as long as it is on a publicly-available webpage, is prominently displayed and clearly identifies the hospital location. The charge data must be easily accessible and digitally searchable. The proposed rule further defines some of these terms.
- The files must be updated at least annually and hospitals should indicate the date of the last update.
Requirements for “Shoppable Services” Charges
In addition to the posting of Standard Charges in a machine-readable format as described above, CMS is also proposing that hospitals post their payer-specific negotiated rates for a set of common “shoppable services.” Shoppable services are defined as a service package that can be scheduled by a patient in advance. The “service package” includes charges for the primary service plus charges for ancillary items and services that are customarily provided with the primary service, such as labs, x-rays, drugs, room charges, therapy, employed professional services, etc. The posting of these shoppable services must be in easily-understandable language and searchable by service, code, or payer.
CMS would require hospitals to post a listing of 300 shoppable services. Those must include services selected by CMS if those services are performed by the hospital. These 70 CMS-selected services are listed in the proposed rule. The hospital will select the remaining shoppable services up to the total of 300 services. In addition to the plain-language description, code, and payer charge, the hospital must include a list of the associated ancillary services with payer charges, and the location where the service is provided (such as the clinic name, if applicable). The hospital must also have a paper copy of this information for shoppable services, like a brochure or booklet, that can be provided to patients within 72 hours of the patient’s request.
Monitoring, Penalties, and Appeals
Finally, CMS is proposing to establish a mechanism for monitoring and the application of penalties for noncompliance. CMS will rely mainly on complaints and consumer reports of non-compliance for now, but may consider audits in the future. For hospitals that are non-compliant, CMS would issue a written warning and request a corrective action plan (CAP) from the hospital. “If the hospital fails to respond to CMS’ request to submit a CAP or comply with the requirements of a CAP, CMS may impose a CMP (up to $300 per day) on the hospital and publicize the penalty on a CMS website.” Hospitals will have the right to appeal CMS’s decision to impose penalties.
Those are the facts, but what is the reality of these proposals? If you have read any articles about this topic, you are aware there are many concerns about CMS’s requirements and even their understanding of the whole process of hospital charges and negotiated rates. For example, one sentence from the Proposed Rule states, “The hospital’s billing and accounting systems maintain the negotiated charges for service packages which are commonly identified in the hospital’s billing system by recognized industry standards and codes.” That statement is not usually true. Hospitals generally negotiate payment rates, not charges. The claims that go out to payers contain the standard charges from the chargemaster. The payer then pays based on negotiated payment rates. Hospitals often do not even know what the payer will be paying until the remittance. This is especially true for payers that pay based on service packages, such as DRGs or other groupings.
Other concerns with CMS’s proposals are legal concerns regarding publishing negotiated prices, the effect of published rates on hospital price decisions, the large volume of different negotiated rates and the fact that associated services are likely to vary from patient to patient based on the patient’s condition and needs. The hospital charge and payment system is complicated. I am no fonder of the current system than many others, but maybe we need to address the system itself first before we try to publicize something that is basically too complicated to communicate.
CMS is accepting comments on the Proposed Rule until 5 p.m. EST on September 27, 2019. I encourage those with concerns about the price transparency proposal to submit their comments.
Debbie Rubio
MEDICARE ADMINISTRATIVE CONTRACTORS (MACS)
There were no new Targeted Probe and Educate (TPE) medical reviews affecting hospitals announced by the Medicare Administrative Contractors (MACs) recently. Novitas JH and JL did release some additional TPE results recently including results for Denosumab, IVIG, HBO, therapy services and DRG validation. Error rates for all of the Novitas reviews were low.
Providers should look for learning opportunities associated with the TPE program on their MACs’ websites or listservs. For example, the Novitas findings referenced above include reasons claims for these services were denied. MACs also sometimes offer educational webinars or teleconferences related to the TPE topics. Palmetto GBA is hosting a Part A Ask the Contractor Teleconference (ACT) on Wednesday, September 18, 2019, at 11 a.m. ET about DRG 682 – Renal Failure. For more information see this Palmetto link.
RECOVERY AUDITORS (RACS)
All Recovery Auditors added a complex review issue for Intravenous Immune Globulin for the Treatment of Autoimmune Blistering Diseases: Medical Necessity and Documentation Requirements. According to the Cotiviti website, “Medical documentation will be reviewed to determine if the use of intravenous immune globulin meets Medicare coverage criteria and is medically reasonable and necessary.” Cotiviti lists the issue twice but indicates both listings are for Region 2. This is likely a typographical error.
SUPPLEMENTAL MEDICAL REVIEW CONTRACTOR (SMRC)
Noridian, the current SMRC, added issues for outpatient hyperbaric oxygen therapy (HBO) and for spinal cord stimulators. They also added some issues for ambulance services. You can view all the current SRMC issues here.
OFFICE OF INSPECTOR GENERAL (OIG)
The August update of the OIG Work Plan included several issues relative to services that could be performed in and billed by hospitals.
- Review of the Medicare DRG Payment Window – “Outpatient services directly related to an inpatient admission are considered part of the inpatient payment and are not separately payable by Medicare.”
- Medicare Part B Services to Medicare Beneficiaries Residing in Nursing Homes During Non-Part A Stays – “An opportunity for fraudulent, excessive, or unnecessary Part B billing exists because NHs may not be aware of the services that the providers bill directly to Medicare, and because NHs provide access to many beneficiaries and their records.”
- Review of Medicare Facet Joint Procedures – “We will review whether payments made by Medicare for facet joint procedures billed by physicians complied with Federal requirements.”
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2019 Update
Update of the HCPCS code set for codes related to drugs and biologicals.
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
July 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.2
October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2019
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.3 Effective October 1, 2019
Notice of New Interest Rate for Medicare Overpayments and Underpayments -4th Qtr Notification for FY 2019
The Medicare contractors shall implement an interest rate of 10.625 percent effective July 17, 2019 for Medicare overpayments and underpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R318FM.pdf
OTHER MEDICARE TRANSMITTALS
Medicare Summary Notice (MSN) Changes to Assist Beneficiaries Enrolled in the Qualified Medicare Beneficiary (QMB) Program
Modifications to Medicare’s claims processing systems to ensure that the Medicare Summary Notice (MSN) appropriately differentiates between QMB claims that are paid and denied and to show accurate patient payment liability amounts for beneficiaries enrolled in QMB.
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA). Since these tests are marketed immediately after approval, the Centers for Medicare & Medicaid Services (CMS) must notify the MACs of the new tests so that they can accurately process claims.
Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements
Appropriate Use Criteria (AUC) related HCPCS modifiers on claims to be accepted January 1, 2020.
MEDICARE SPECIAL EDITION ARTICLES
Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations
Revised to provide an update on Round 3 testing and to announce a delay of full implementation until October 2019.
Pre-Diabetes Services: Referring Patients to the Medicare Diabetes Prevention Program
Information on this new Medicare covered service.
Emergency Medical Treatment and Labor Act (EMTALA) and the Born-Alive Infant Protection Act
Medicare Plans to Modernize Payment Grouping and Code Editor Software
CMS is modernizing its grouping and code editor software. Medicare processes all Original Medicare institutional claims through one of three sub-systems within the Fiscal Intermediary Shared System (FISS):
- The Medicare Code Editor (MCE)
- The Inpatient Grouper (MS-DRG)
- The Integrated Outpatient Code Editor (IOCE).
These sub-systems are built with an antiquated programming language (Assembler) that is difficult to extend, maintain, support and test. Modernizing these programs will protect CMS from future quality and integration risks.
MEDICARE COVERAGE UPDATES
Acupuncture Coverage for Chronic Low Back Pain
CMS proposes to cover acupuncture for chronic low back pain for Medicare beneficiaries enrolled in approved studies.
https://www.cms.gov/medicare-coverage-database/details/nca-tracking-sheet.aspx?NCAId=295
Update to Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency Diseases in the Home
Updates the list of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for the coverage of IVIG for treatment of Primary Immune Deficiency Diseases (PIDD) in the home.
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Cardiac Device Credits: Medicare Billing
Palmetto GBA Hyperbaric Oxygen Therapy Module
Explains HBO therapy, covered and non-covered conditions as indicated per NCD 20.29 for treatment, as well as documentation guidelines pertinent to establishing medical necessity when submitting claims to Medicare
https://www.palmettogba.com/internet/eLearn3.nsf/HyperbaricOxygenTherapy/story_html5.html
OTHER MEDICARE UPDATES
KEPRO Updates for Healthcare Providers
Since Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) started transitioning into a new 5-year contract with the Centers for Medicare & Medicaid Services (CMS), KEPRO has been making necessary changes to help streamline processes. During the next few weeks, we will share periodic updates with you in a special bulletin.
https://www.keproqio.com/providers/transition/
Comprehensive Care for Joint Replacement Model
Jun 27, 2019 Announcement: Second annual evaluation report and associated materials posted.
https://innovation.cms.gov/initiatives/cjr
ESRD Treatment Choices (ETC) Model
Proposed required model aims to encourage greater use of home dialysis and kidney transplants for Medicare beneficiaries with end-stage renal disease (ESRD).
https://innovation.cms.gov/initiatives/esrd-treatment-choices-model
Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First
“Within 60 days of the date of this order, the Secretary of Health and Human Services shall propose a regulation, consistent with applicable law, to require hospitals to publicly post standard charge information…”
CMS Announces Extension of Enforcement Discretion Period for Laboratory Date of Service Exception Policy Under the Medicare Clinical Laboratory Fee Schedule Until January 2, 2020
During the enforcement discretion period, hospitals may continue to bill for advanced diagnostic laboratory tests (ADLTs) and molecular pathology tests that would otherwise be subject to the laboratory DOS exception.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Lab-DOS-Policy.html (see Downloads section)
CY 2020 Home Health Prospective Payment System (HH PPS) Proposed Rule
Proposes routine updates to the home health payment rates for calendar year (CY) 2020, and also includes: a proposal to modify the payment regulations pertaining to the content of the home health plan of care; a proposal to allow therapist assistants to furnish maintenance therapy; and a proposal related to the split percentage payment approach under the Home Health Prospective Payment System (HH PPS). Finally, this rule will include proposals related to the implementation of the permanent home infusion therapy benefit in 2021.
Rule: https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-14913.pdf
Monday, July 29, 2019, CMS released three important Medicare proposed payment rules for 2020:
- The OPPS and ASC Proposed Rule - https://www.cms.gov/newsroom/press-releases/cms-takes-bold-action-implement-key-elements-president-trumps-executive-order-empower-patients-price
- The MPFS Proposed Rule - https://www.cms.gov/newsroom/press-releases/trump-administrations-patients-over-paperwork-delivers-doctors
- The ESRD and DME Proposed Rule - https://www.cms.gov/newsroom/press-releases/new-cms-proposals-strengthen-medicare-unleash-innovation-and-promote-competition-provide-kidney
MEDICARE TRANSMITTALS – RECURRING UPDATES
July 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.2
July 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Describes changes to and billing instructions for various payment policies implemented in the July 2019 OPPS update.
OTHER MEDICARE TRANSMITTALS
Documentation of Medical Necessity of the Home Visit; and Physician Management Associated with Superficial Radiation Treatment
Removes the requirement that the medical record show a home visit was medically necessary instead of an office or outpatient visit and adds information on E&M code that may be billed with superficial radiation treatment.
New to State Operations Manual (SOM), Appendix X, Survey Protocol and Interpretive Guidelines for Organ Transplant Programs
Adds Appendix X to the SOM to outline the survey process and interpretive guidelines for the Conditions of Participation for organ transplant programs.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R189SOMA.pdf
Updates to Medicare Financial Management Manual Chapter 4, Section 20 and 20.1 Demand Letters
Every demand letter, regardless of the cause of the overpayment or the status of the provider, shall meet certain requirements as to form and content.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R316FM.pdf
MEDICARE SPECIAL EDITION ARTICLES
Chimeric Antigen Receptor (CAR) T-Cell Therapy Revenue Code and HCPCS Setup Revisions
Updated reporting instructions for CAR T-Cell Therapy.
MEDICARE COVERAGE UPDATES
Decision Memo for Transcatheter Aortic Valve Replacement (TAVR) (CAG-00430R)
The Centers for Medicare & Medicaid Services (CMS) will cover Transcatheter Aortic Valve Replacement (TAVR) for the treatment of symptomatic aortic valve stenosis through Coverage with Evidence Development (CED).
https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=293
MEDICARE PRESS RELEASES
CMS Seeks Public Input on Patients over Paperwork Initiative to Further Reduce Administrative, Regulatory Burden to Lower Healthcare Costs
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Outpatient Rehabilitation Therapy Services: Comply with Medicare Billing Requirements
- Bill Correctly for Device Replacement Procedures
Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements
OTHER MEDICARE UPDATES
April-June 2019 Quarterly Provider Updates
CMS publishes this Update to inform the public about the following:
- Regulations and major policies completed or cancelled.
- New/Revised manual instructions
Kepro BFCC-QIO FAQs for Healthcare Providers
Frequently asked questions (FAQs) related to KEPRO’s services.
Yes! Help me improve my Medicare FFS business.
Please, no soliciting.
We are an environmentally conscious company, dedicated to living “green” both at work and as individuals.
