Knowledge Base Category -
MEDICARE TRANSMITTALS – RECURRING UPDATES
Notice of New Interest Rate for Medicare Overpayments and Underpayments -3rd Qtr Notification for FY 2019
The Medicare contractors shall implement an interest rate of 10.375 percent effective April 17, 2019 for Medicare overpayments and underpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R313FM.pdf
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)
A maintenance update of International Classification of Diseases, 10th Revision (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.
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Claim Status Category and Claim Status Codes Update
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2019 Update
Updates the HCPCS code set for codes related to drugs and biologicals.
OTHER MEDICARE TRANSMITTALS
Implementation to Exchange the List of Enrollment in Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System
Introduces the enrollment process for the providers who intend to get their Additional Documentation Request (ADR) letters electronically (as eMDR) through their registered Health Information Handler.
Re-implementation of the AMCC Lab Panel Claims Payment System Logic
Because CMS no longer has payment logic to roll up panel pricing for organ or disease-oriented panels (also known as Automated Multi-Channel Chemistry or AMCC tests), laboratories must report the HCPCS code for the AMCC panel test where appropriate and not report separately the tests that make up that panel.
Documentation of Evaluation and Management Services of Teaching Physicians
A change in policy of documentation for teaching physicians providing evaluation and management (E/M) services.
Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)
Effectuates changes to the SNF Prospective Payment System (PPS) that are required for the PDPM. These changes were finalized in the FY 2019 SNF PPS Final Rule (83 FR 39162). SNFs billing on Type of Bill (TOB) 21X and hospital swing bed providers billing on TOB 18X, (subject to SNF PPS) will be subject to these requirements.
Reporting the HCPCS Level II Modifiers of the Patient Relationship Categories and Codes
Provides educational information regarding reporting of the HCPCS Level II code modifiers for the Patient Relationship Categories and Codes (PRC).
Additional Processing Instructions to Update the Standard Paper Remit (SPR)
Effective October 1, 2019, MACs will mask the Patient Control Number field (also named the Patient CNTRL Number) or the Patient Account Number (ACNT) field on any print file used to create an SPR for mailing if it contains a HICN or SSN in accordance with the Social Security Number (SSN) Fraud Prevention Act of 2017.
MEDICARE SPECIAL EDITION ARTICLES
Proper Use of Modifier 59
Clarifies existing policy on the proper use of Modifier 59. Revised article to correct updated CPT code.
MEDICARE COVERAGE UPDATES
National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)
CMS covers diagnostic laboratory tests using next generation sequencing when performed in a CLIA-certified laboratory when ordered by a treating physician and when specific requirements are met.
Delay in Final Chimeric Antigen Receptor (CAR) T-cell therapy National Coverage Determination
CMS will not be issuing a final National Coverage Determination on CAR T-cell therapy for cancer today (5-17-19), but a decision is forthcoming.
MEDICARE PRESS RELEASES
CMS outlines comprehensive strategy to foster innovation for transformative medical technologies
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities
OTHER MEDICARE UPDATES
2020 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Acute Care Hospital (LTCH) Prospective Payment System Proposed Rule
https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-08330.pdf
Fact Sheet for Proposed Rule - https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2020-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acute
BFCC-QIO Contract Awarded for 12th Scope of Work to Start July 2019
The 11th Scope of Work is coming to an end. On April 30th KEPRO and LIVANTA were again awarded the BFCC-QIO contracts for the 12th Scope of Work (SOW) that will run from 2019 – 2023
Temporary Pause of BFCC-QIO Short Stay and HWDRG Reviews
CMS has temporarily paused the performance of both Short Stay reviews and Higher Weighted Diagnosis-Related Group (HWDRG) reviews by the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs). CMS took this action to procure a new BFCC-QIO contractor. Going forward, Short Stay reviews and HWDRG reviews will resume with a single organization performing reviews on a national basis. CMS anticipates a contract award to be issued by the 3rd quarter of calendar year 2019.
https://qioprogram.org/qionews/articles/temporary-pause-bfcc-qio-short-stay-and-hwdrg-reviews
Local Coverage Determination (LCD) Process Modernization Qs & As
Describes recent changes to the LCD process.
https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/LCD_QsAs.pdf
System Edits Will Be Activated for OPPS Providers with Multiple Service Locations
On July 1, 2019, CMS will begin enforcing edit requirements for Outpatient Prospective Payment System (OPPS) providers with multiple service locations submitting claims to Medicare.
MEDICARE TRANSMITTALS – RECURRING UPDATES
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits
The new HCPCS codes for 2019 that are subject to and excluded from Clinical Laboratory Improvement Amendments (CLIA) edits.
April 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.1
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
April 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Describes changes to, and billing instructions for, various payment policies implemented in the April 2019 OPPS update.
OTHER MEDICARE TRANSMITTALS
Evaluation and Management (E/M) When Performed with Superficial Radiation Treatment
Allows providers to bill E/M codes 99211, 99212, and 99213 for Levels I through III, when performed with superficial radiation treatment delivery.
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
Assist the laboratory community in meeting the requirements under Section 1834A of the Social Security Act (the Act) for the Medicare Part B Clinical Laboratory Fee Schedule (CLFS). Includes clarifications for determining
- whether a hospital outreach laboratory meets the requirements to be an “applicable laboratory,”
- the applicable information (that is, private payor rate data) that must be collected and reported to CMS,
- the entity responsible for reporting applicable information to CMS,
- the data collection and reporting periods, and
- the schedule for implementing the next private payor-rate based CLFS update.
New Medicare Beneficiary Identifier (MBI) Get It, Use It
MEDICARE COVERAGE UPDATES
National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)
CMS covers diagnostic laboratory tests using next generation sequencing when performed in a Clinical Laboratory Improvement Amendments- certified laboratory when ordered by a treating physician and when specific requirements are met.
MEDICARE PRESS RELEASES
CMS Updates Consumer Resources for Comparing Hospital Quality
CMS updated hospital performance data on the Hospital Compare website and on data.medicare.gov. This data includes specific measures of hospitals’ quality of care, many of which are updated quarterly, and the Overall Hospital Star Ratings, which were last updated in December 2017. The data are collected through CMS’s Hospital Quality Initiative programs.
CMS Updates Drug Dashboards with Prescription Drug Pricing and Spending Data
Updated with 2017 data.
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Bill Correctly for Device Replacement Procedures
OTHER MEDICARE UPDATES
KEPRO Winter 2019 Care Review Connections Newsletter
A quarterly e-newsletter from your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).
https://www.keproqio.com/providers/winter-2019-acute-newsletter/
Guidelines for Achieving a Compliant Query Practice—2019 update
“Guidelines for Achieving a Compliant Query Practice” was produced through the joint effort of the Association of Clinical Documentation Improvement Specialists (ACDIS) and the American Health Information Management Association (AHIMA). Both associations collaborated on the creation of this practice brief and approved its contents, and as such it represents the recommended industry standard for provider queries.
This practice brief supercedes one published in 2016 and all previous versions.
https://acdis.org/resources/guidelines-achieving-compliant-query-practice%E2%80%942019-update
If your hospital has a hospital outreach laboratory that furnishes laboratory testing to non-patients, you may be required to collect and report private payor lab rates and volumes to Medicare. A non-patient is a patient that is neither an inpatient nor an outpatient of a hospital.
Non-patients are those patients that:
- Have a specimen submitted for analysis to a hospital and the patient is not physically present at the hospital;
- The patient did not receive other outpatient services at the hospital on the same day the specimen was collected; or
- The specimen was not collected by an employee of the hospital or of a facility provider-based to the hospital.
Hospital laboratories may bill Medicare under their own NPI separate from the hospital NPI. Hospital laboratories that bill under the hospital NPI, bill for non-patient specimens on Form CMS-1450 (UB-04) 14x Type of Bill (TOB).
The Protecting Access to Medicare Act of 2014 (PAMA) made significant changes to the way in which Medicare payments for laboratory tests paid under the Clinical Laboratory Fee Schedule (CLFS) are determined. Under the CLFS final rule “Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule” (CMS-1621-F), which was published in June 2016 and implemented the PAMA requirements, private payor rates became the basis for the revised CLFS rates beginning January 1, 2018. Medicare obtains the data for the private payor rates from applicable laboratories that are required to report their private payor payments and volumes to CMS. When this rule first came out the definition of applicable reporting labs had to do with the percentage of Medicare services for a particular NPI that were paid under the CLFS or the physician fee schedule. Since hospital Medicare revenues are mainly from inpatient and outpatient prospective payment systems (IPPS and OPPS), most hospital labs did not qualify as an applicable reporting laboratory with the exception of hospital laboratories that had their own NPI number. In the 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, CMS changed the definition of an applicable reporting laboratory to use the Medicare revenue from a hospital 14x type of bill for the data collection period beginning January 1, 2019.
On February 27, 2019, Medicare published MLN Matters Article SE19006 that includes a lengthy discussion of the reporting requirements including “clarifications for determining whether a hospital outreach laboratory meets the requirements to be an “applicable laboratory,” the applicable information (that is, private payor rate data) that must be collected and reported to the Centers for Medicare & Medicaid Services (CMS), the entity responsible for reporting applicable information to CMS, the data collection and reporting periods, the schedule for implementing the next private payor-rate based CLFS update” and information about a condensed data reporting option for reporting entities.
For many hospitals that perform outreach testing, this will be a big deal. The reporting entity is based on the Tax Identification Number (TIN) but data is reported for each individual NPI that meets the definition of an applicable laboratory. This means the first step is determining if your laboratory meets the definition of an applicable reporting laboratory. If your hospital lab bills under its own NPI, you likely dealt with determining if you were a reporting laboratory for the first reporting period.
Labs are required to report data if they:
- Have more than $12,500 in Medicare revenues from laboratory services on the Clinical Laboratory Fee Schedule (CLFS) during a 6-month data collection period, and
- Receive more than 50 percent of their Medicare revenues from CLFS and physician fee schedule services during a data collection period”
Hospital labs billing under the hospital’s NPI now use the 14x TOB for these calculations. Since 14x revenues are “non-patient” services, they consist exclusively (or mostly) of lab services, meaning the percentage will likely always exceed 50%. The means if your hospital outreach lab’s 14x revenues equal or exceed $12,500 in the 6-month reporting period, then you are required to report the lab private payor data to Medicare.
If you are an applicable laboratory, you must report each private payor rate and volume for each lab test subject to the data collection and reporting requirements. You can find a list of the lab tests subject to reporting in the Downloads section of the Medicare CLFS PAMA webpage – the document is titled CLFS Applicable Information HCPCS Codes. Private payors are defined as a health insurer issuer, a group health plan, a Medicare Advantage plan or a Medicaid Managed Care Organization.
Labs report the final amount paid by a private payor including patient cost sharing amounts and secondary insurer payments. If an applicable laboratory has more than one payment rate for the same private payor for the same test, or more than one payment rate for different payors for the same test, the reporting lab will report each such payment rate and the volume for the test at each such rate. There may be some insurances that do not pay individual amounts per HCPCS code, such as an insurance that pays under capitation or under a claim-level payment (such as, EAPGs for example). In this case, if the final private payor rate amount paid by HCPCS code and the associated volume paid at that final rate cannot be determined, the payment amount is not a private payor rate for purposes of applicable information and therefore is not reported to CMS.
Hospital laboratories that meet the applicable reporting status based on billing on the 14X TOB report only applicable information attributed to the lab’s non-hospital patients. This means the hospital must distinguish private payor payments made for lab tests furnished to non-patients from private payor payments made for lab tests furnished to hospital inpatients and outpatients. Only the private payor rates and volumes of laboratory tests furnished to non-patients are to be reported to CMS.
The next data collection period for this reporting began January 1, 2019 and goes through June 30, 2019. Then there is a six-month review and validation period from July 1, 2019-December 31, 2019. Applicable laboratories will report their data between January 1, 2020 and March 31, 2020. This data will be used to set the Clinical Lab Fee Schedule (CLFS) rates beginning in year 2021. The data collection, reporting and setting of new rates occurs every 3 years.
There is a new option available for condensed reporting at the TIN level. The TIN level reporting entity may combine the volume paid at the same private payor rate for the same HCPCS code for its component applicable laboratories. The condensed data reporting is only permitted when a specific lab test HCPCS code is paid at the same private payor rate to more than one applicable lab under the same TIN. The reporting entity must select one NPI as the reporting NPI when using this condensed data reporting. The MLN Matters article gives examples of how the condensed reporting would work. This is only an option if a reporting entity has multiple applicable laboratories for which it is reporting.
This reporting is not voluntary, optional, or discretionary. If your laboratory qualifies as an applicable reporting laboratory, you must ensure accurate collection and reporting of applicable information. There is a lot to consider and a lot of preparation prior to reporting. This article is only a cursory explanation of the process. I encourage hospitals to first determine if the reporting requirements apply to you and if they do, begin by reading all the Medicare information on the data collection and reporting process. I am sure after further study, you will agree, this is a big deal.
Resources:
Debbie Rubio
A friend of mine recently had back surgery and she is following up her hospital stay with up to 21 days in a Skilled Nursing Facility (SNF) for rehabilitation. Most of you reading this probably realized she has Medicare when I said “up to 21 days” and that the stay is for “skilled” care. She will be receiving intensive physical and occupational therapy to prepare her to be able to handle activities of daily living when she is discharged back to her home. This is a great Medicare benefit, but as most Medicare benefits, there are stipulations and rules that must be followed.
For SNF placement:
- The patient must have been an inpatient of a hospital for a medically necessary stay of at least 3 consecutive calendar days, not counting the date of discharge;
- SNF services must be ordered by a physician and provided by, or under the direct supervision of, skilled nursing or rehabilitation professionals;
- The patient must be admitted to the SNF and receive the needed care within 30 calendar days after the date of discharge from a hospital; and
- The SNF services must be for a condition previously treated at a hospital.
Luckily for my friend, she meets all of the above criteria.
However, a recent OIG Report found that Medicare continues to make improper payments for SNF services because the services do not meet the 3-day rule. The OIG estimates overpayments of almost $85 million for CY 2013-2015 (the audit period). Notice I said “continues” to make improper payments; that is because the OIG has performed 27 prior audits of this same issue with similar findings. So, what is the problem and how does the OIG recommend correcting it? AND – is CMS on board with the OIG’s recommendations?
The basic problem is that SNFs are billing for stays when the patient did not have a 3-day qualifying stay and Medicare is making payment for these services. SNFs are required to report occurrence span code “70” to provide the dates of a qualifying hospital stay of at least 3 consecutive days on their Medicare claim. SNFs usually obtain the information about the hospital stay from the hospital. In the hospital setting, case managers or discharge planners make the discharge plans for patients and should consider the above criteria when placing a patient in a SNF setting.
Problem #1 – Medicare Edits:
Medicare claims processing systems should have edits in place to verify whether SNF claims meet the 3-day rule based on the dates reported with occurrence span code “70.” Common Working File (CWF) edits reject claims if the dates reported by the SNF or if the dates on the associated hospital inpatient claim do not span 3 or more calendar days. CMS stated the CWF edits were not enabled and/or working as they should for the time frame of this audit. “CMS said that it enabled the CWF qualifying inpatient hospital stay edit for SNF claims effective April 2018.” Even with the edits working properly, there are reasons they are not always effective. According to the OIG report, this is due to “incorrect or incomplete SNF and hospital claim data, a lack of access to the U.S. Department of Veterans Affairs (VA) or private-pay hospital claims that should be considered while calculating the length of a qualifying hospital stay, and timing differences between the submission of hospital claims and SNF claims…”
Turning on the edits will help a lot, but obviously there are other issues.
Problem # 2 – Counting Incorrectly:
This occurs when a combination of inpatient and non-inpatient hospital days is counted to determine whether the 3-day rule was met. For example, if a patient is seen in the Emergency Department and not admitted as an inpatient until the next day, the day of the ED visit is not counted as an inpatient day. This gets even more confusing when you consider patients receiving observation services. Medicare allows hospitals to consider nights spent as an outpatient (such as outpatient receiving observation) to meet the 2-midnight benchmark for determining inpatient status under the 2-midnight rule. These outpatient days do not count toward a SNF 3-day qualifying stay. Also, the day of discharge is not counted toward the 3 days. Mistakes in counting days incorrectly may be made by SNF or hospital personnel and then reported incorrectly down the line and eventually on the claim to Medicare.
Problem # 3 – Ineffective Communication and Notification
The OIG seems to think this is a big issue. Hospitals may pass along inaccurate information to the SNF which the SNF then uses to accept the patient and bill Medicare. If the SNF was unaware the information was incorrect and billed the claim thinking their information was correct, this raises the issue of liability. If the SNF did not know, should they be liable for the cost? If they are not liable, does liability then fall to the patient? The OIG was often unable to determine “whether SNFs were at fault for the improper payments. The “at fault” consideration affects the determination of whether the SNF or beneficiary is financially liable for the overpayment.” This brings up the issue of patient knowledge – patients are often not really aware of their status despite CMS forms such as the Medicare Outpatient Observation Notice (MOON) and the Important Message from Medicare. SNFs are allowed, but not required, to give the patient a SNF Advance Beneficiary Notice (SNFABN) if Medicare is expected to deny payment for the SNF stay when the 3-day rule is not met.
“The limitation on liability provision,” provides financial relief to beneficiaries and providers by permitting Medicare payment to be made if the provider or beneficiary was without fault with respect to the overpayment. Medicare may waive recovery “if it would cause financial hardship or would not be equitable and in good conscience.” If this happens, Medicare absorbs the financial cost of the error.
The OIG recommends CMS:
- “Require hospitals to provide a written notification to beneficiaries whose discharge plans include posthospital SNF care, clearly stating how many inpatient days of care the hospital provided and whether the 3-day rule for Medicare coverage of SNF stays has been met. If necessary, CMS should seek statutory authority to do so.
- Require SNFs to obtain from the hospital or beneficiary, at the time of admission, a copy of the hospital’s written notification to the beneficiary and retain it in the beneficiary’s medical record. (See our second recommendation.) If necessary, CMS should seek statutory authority to do so.
- Require SNFs to provide written notice to beneficiaries if Medicare is expected to deny payment for the SNF stay when the 3-day rule is not met. If necessary, CMS should seek statutory authority to do so.”
Interestingly, CMS opposes these recommendations, stating the current notifications (MOON and Important Message) are sufficient notification to the beneficiary. CMS also said that it did not believe it would be appropriate to include a requirement referencing Medicare coverage criteria for SNF care as part of the hospital discharge planning requirements and that it encourages SNFs to provide SNFABNs to beneficiaries when the 3-day rule is not met.
As noted above, CMS did enable the CWF edits and agreed to recommendations to educate hospitals and SNFs about their responsibilities to communicate accurate information to each other and to the Medicare beneficiary.
Remember the estimated overpayment for the 3-year time frame of this audit was over $84 million. Prior OIG reviews estimated CMS paid $169 million for SNF services in calendar years (CYs) 1996 through 2001 (6-year period) when the 3-day rule was not met. Both of these estimates average to over $28 million a year, so essentially there was no improvement in overpayments from prior years reviewed by the OIG. It will be interesting to see if simply claim processing edits and education can make a difference in years to come.
Debbie Rubio
While a majority of the country is in the grips of below freezing weather, here in the South our promised snow did not happen and temperatures by the first of next week are forecast to be in the 70’s. Some flowers, such as jonquils, are beginning to bloom and whether from the changing weather patterns or from early bloomers, I have a sinus headache. This time next year, many hospital laboratories will be in the middle of another large headache – that of reporting private payor data for clinical diagnostic laboratory tests (CDLTs) to Medicare.
The Protecting Access to Medicare Act of 2014 (PAMA) made significant changes to the way in which Medicare payments for laboratory tests paid under the Clinical Laboratory Fee Schedule (CLFS) are determined. Under the CLFS final rule “Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule” (CMS-1621-F), which was published in June 2016 and implemented the PAMA requirements, private payor rates became the basis for the revised CLFS rates beginning January 1, 2018. Medicare obtains the data for the private payor rates from applicable laboratories that are required to report their private payor payments and volumes to CMS. When this rule first came out the definition of applicable reporting labs had to do with the percentage of Medicare services for a particular NPI that were paid under the CLFS or the physician fee schedule. Since hospital Medicare revenues are mainly from inpatient and outpatient prospective payment systems (IPPS and OPPS), most hospital labs did not qualify as an applicable reporting laboratory with the exception of hospital laboratories that had their own NPI number.
In the 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, CMS changed the definition of an applicable reporting laboratory to use the Medicare revenue from a hospital 14x type of bill for the data collection period beginning January 1, 2019. The official definition for applicable reporting laboratories is:
“Laboratories, including physician offices laboratories and hospital outreach laboratories that bill using a 14X TOB are required to report laboratory test HCPCS codes, associated private payor rates, and volume data if they:
- Have more than $12,500 in Medicare revenues from laboratory services on the Clinical Laboratory Fee Schedule (CLFS), and
- Receive more than 50 percent of their Medicare revenues from CLFS and physician fee schedule services during a data collection period”
As explained in the January 22, 2019 ‘Clinical Diagnostic Laboratories to Collect and Report Private Payor Rates Call’, hospitals will divide the CLFS and PFS revenues attributed to 14x Type of Bill by their total 14x
revenues. Since 14x revenues are “non-patient” services, they consist exclusively (or mostly) of lab services, meaning the percentage will likely always exceed 50%. This means if your hospital outreach lab’s 14x revenues equal or exceed $12,500 in the 6-month reporting period, then you are required to report the lab private payor data to Medicare.
Using Medicare claims data from our sister company, RealTime Medicare Data (RTMD), I looked at the 14x revenue for a number of hospitals and I was surprised that most hospitals easily surpassed the $12,500 per 6-months threshold for reporting. The current data collection period began January 1, 2019 and goes through June 30, 2019. The reporting period for this collection period is January 1, 2020 through March 31, 2020. This gives hospitals time to evaluate their status and prepare for reporting.
I recommend hospitals first verify they are using the 14x type of bill correctly. The 14x type of bill is used to bill non-patient lab services, such as when a specimen is sent to the hospital lab for testing from a physician’s office. Patients that are referred to your laboratory for testing and actually physically come to the hospital lab for specimen collection are outpatients. Outpatient testing is billed to Medicare on a 13x type of bill. Although the data collection period has already begun, if you are not using the 14x bill type correctly, now is the time to correct it.
Hospitals then need to determine the amount of their 14x revenues for a six-month period. The current collection period of January-June 2019 will be the official period for determining 14x lab revenues for reporting purposes, but hospitals can estimate if they will meet the criteria based on prior data. If it appears your hospital laboratory will meet the definition of an applicable reporting lab, someone at your facility needs to learn the requirements for reporting so you are ready next year. Here are some resources to get you started with the process.
- Medicare's Laboratory PAMA webpage – a wealth of information and links to other resources on this page. If you are an applicable reporting lab, you will want to check out the CLFS Data Collection System User Guide.
- Medicare FAQs on the Final Rule (at the time this article was written, these FAQs were not yet updated with the new 2019 applicable lab definition)
- National Provider Call January 22 2019 – this website includes the presentation, audio recording, and transcript of this call. CMS will be having additional calls on this topic so be on the lookout for these.
The January 22, 2019 National Provider Call explained how to determine if you are a reporting laboratory under the new 14x definition. The CMS presenters were unsure exactly what data would be required to be reported to Medicare – was it only 14x data, or was the 14x data only for determining reporting status and all lab non-patient and outpatient data would have to be reported. They promised to clarify this in upcoming sub-regulatory guidance.
In general, reporting labs have to report the private payor rate for each test for which final payment has been made during the data collection period, the associated volume for each test, and the specific HCPCS code associated with the test. If an applicable laboratory has more than one payment rate for the same private payor for the same test, or more than one payment rate for different payors for the same test, the reporting entity will report each such payment rate and the volume for the test at each such rate.
There may be some insurances that pay a lump sum amount per claim, instead of individual line item payments, such as an insurance that pays under EAPGs for example. In this case, if the final private payor rate amount paid by HCPCS code and the associated volume paid at that final rate cannot be determined, the payment amount is not a private payor rate for purposes of applicable information and therefore is not reported to CMS.
Even from this cursory discussion of the required reporting for private payor lab rates, you can tell it will certainly be a huge headache. You cannot change that, but you can start now to know where you stand and what to expect as the reporting period approaches.
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
January 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Update to Medicare Deductible, Coinsurance and Premium Rates for 2019
International Classification of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – REVISED
A maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs) as a result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2202OTN.pdf
OTHER MEDICARE TRANSMITTALS
Incomplete Colonoscopies Billed with Modifier 53 for Critical Access Hospital (CAH) Method II Providers
Implements the payment methodology for incomplete colonoscopy procedures (Healthcare Common Procedure Coding System (HCPCS) codes 44388, 45378, G0105, and G0121 with a modifier 53) for CAH Method II providers.
Correction to Common Working File (CWF) Informational Unsolicited Response (IUR) 7272 for Intervening Stay
Correction to edit for IPPS hospital claim with patient discharge status code ‘61’ (Discharged/transferred within this institution to a hospital-based Medicare approved swing bed) and a home health claim is received with an admission date equal to or within 3 days of the history IPPS claim’s discharge date and there is an intervening swing bed claim in history.
Hospital and Critical Access Hospital (CAH) Swing-Bed Manual Revisions
Clarifies policies related to hospitals and CAHs with respect to services furnished to swing-bed patients, including policies related to pass-through reimbursement for Certified Registered Nurse Anesthetist (CRNA) services.
Update to Bone Mass Measurements (BMM) Code 77085 Deductible and Coinsurance
Instructs contractors to waive deductible and coinsurance for BMM code 77085.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4150CP.pdf
Removal of the Provider Requirement for Reporting on an Institutional Claim a Value Code (VC) 05 - Professional Component-Split Implementation
Removes editing for the requirement of value code 05 on an institutional claim.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2178OTN.pdf
User CR: Fiscal Intermediary Shared System (FISS) - Implementation of the Molecular Diagnostic Services (MolDX)
Adds a MolDX test identification (ID) field to FISS so providers will be able to input a unique test ID into their claims at the detail line level.
Common Working File (CWF) Provider Queries National Provider Identifier (NPI) and Submitter Identification (ID) Verification
The Common Working File (CWF) will require verification of the National Provider Identifier (NPI) and Submitter Identification (ID) when Medicare Part A providers request Medicare beneficiary eligibility and entitlement data via the CWF provider inquiry screens.
MEDICARE PRESS RELEASES
CMS finalizes Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System changes for 2019 (CMS-1695-FC)
Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Cochlear Devices Replaced Without Cost
- Reporting Changes in Ownership
- Ophthalmology Services: Questionable Billing and Improper Payments
November Patients Over Paperwork Newsletter
Updates on the Administration’s ongoing work to reduce administrative burden and improve the customer experience for beneficiaries.
https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/PoPNovember2018.pdf
Medicare Billing: Form CMS-1450 and the 837 Institutional Educational Booklet
CERT Article on Patient Discharge Codes
OTHER MEDICARE UPDATES
Medicare Letter to Clinicians
Outlines how the agency is reducing burden through reform of documentation and coding requirements.
Contract Award for A/B MAC Jurisdiction 8
On November 1, 2018, CMS awarded Wisconsin Physicians Service Government Health Administrators (WPS) (the incumbent contractor for this A/B MAC jurisdiction) a new contract for the administration of Medicare Part A and Part B Fee-for-Service (FFS) claims in the states of Indiana and Michigan.
MEDICARE TRANSMITTALS – RECURRING UPDATES
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2019
The January 2019 quarterly release of the edit module for clinical diagnostic laboratory services.
Quarterly Influenza Virus Vaccine Code Update - January 2019
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4141CP.pdf
2019 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
Updates to edits to allow only those services that are excluded from SNF CB to be paid separately.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 1st Qtr Notification for FY 2019
The Medicare contractors shall implement an interest rate of 10.125 percent effective October 17, 2018 for Medicare overpayments and underpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R307FM.pdf
OTHER MEDICARE TRANSMITTALS
Implementation of the Award for the Jurisdiction F (J-F) Part A and Part B Medicare Administrative Contractor (JF A/B MAC)
The Jurisdiction JF A/B MAC recompetition procurement was recently awarded to Noridian Healthcare Solutions, LLC (Noridian), the incumbent contractor for this workload.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2143OTN.pdf
Guidance Regarding the Use of Statistical Sampling for Overpayment Estimation
Updates instructions for Unified Program Integrity Contractors (UPICs), Recovery Audit Contractors (RACs), the Supplemental Medical Review Contractor (SMRC), and Medicare Administrative Contractors (MAC) regarding the use of statistical sampling in their reviews and estimation of overpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R828PI.pdf
Local Coverage Determinations (LCDs)
CMS is updating the Medicare Program Integrity Manual with detailed changes to the Local
Coverage Determination (LCD) process.
Fiscal Year (FY) 2019 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Changes
Implements Fiscal Year (FY) 2019 policy changes for the Inpatient Prospective Payment System (IPPS) and LTCH PPS.
Updating Calendar Year (CY) 2019 Medicare Diabetes Prevention Program (MDPP) Payment Rates
This MLN Matters Article is intended for organizations enrolled as Medicare Diabetes Prevention Program (MDPP) suppliers billing Medicare Administrative Contractors (MACs) for MDPP services provided to Medicare beneficiaries.
Medical Review of Diagnostic Laboratory Tests
Clarifies how medical review contractors should review orders for diagnostic laboratory test claims.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R836PI.pdf
MEDICARE SPECIAL EDITION ARTICLES
Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations
Medicare systems will validate service facility location to ensure services are being provided in a Medicare enrolled location based on the information submitted on the Form CMS-855A submitted by the provider and entered into the Provider Enrollment, Chain and Ownership System (PECOS).
2018-2019 Influenza (Flu) Resources for Health Care Professionals
MEDICARE COVERAGE UPDATES
Magnetic Resonance Imaging (MRI)
Effective for claims with dates of service on and after April 10, 2018, Medicare will allow for MRI coverage for beneficiaries with an Implanted Pacemaker (PM), Implantable Cardioverter Defibrillator (ICD), Cardiac Resynchronization Therapy Pacemaker (CRT-P), or Cardiac Resynchronization Therapy Defibrillator (CRT-D).
MEDICARE PRESS RELEASES
2019 Medicare Parts A & B Premiums and Deductibles
The standard monthly premium for Medicare Part B enrollees will be $135.50 for 2019. The annual deductible for Medicare Part B beneficiaries is $185 in 2019. The Medicare Part A inpatient deductible that beneficiaries will pay when admitted to the hospital is $1,364 in 2019.
https://www.cms.gov/newsroom/fact-sheets/2019-medicare-parts-b-premiums-and-deductibles
MEDICARE EDUCATIONAL RESOURCES
October 2018 Medicare Quarterly Provider Compliance Newsletter
Assists health care professionals to understand the latest findings identified by MACs and other contractors such as Recovery Auditors and the Comprehensive Error Rate Testing (CERT) review contractor, in addition to other governmental organizations such as the Office of the Inspector General (OIG).
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims
OTHER MEDICARE UPDATES
September 2018 Patients Over Paperwork Newsletter
An update on CMS’s ongoing work to reduce administrative burden and improve the customer experience while putting patients first.
https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/POPSeptember2018Newsletter.pdf
MMP initially ran this article September 12, 2018, click here to read the original article. Since then CMS posted a correction to the 2019 IPPS Final Rule on October 3rd. This correction included the following important update to inpatient cases involving the drug VABOMERE™ which is available for a new technology add-on payment.
Notice in 2019 IPPS Final Rule Correction published in the Federal Register October 3, 2018:
“On page 41311, we made a typographical error in describing which National Drug Code (NDC) will be used to identify cases involving VABOMERE™ that are eligible for new technology add-on payments in FY 2019. Specifically, we are correcting the NDC code of 65293–0009–01, which erroneously was missing an extra digit. In addition, we were made aware after the final rule that NDC 70842–0120–01 can also be used to identify cases of VABOMERETM. Therefore, cases involving the use of VABOMERE™ that are eligible for new technology add-on payments in FY 2019 will be identified with either of the following NDCs: 65293–0009–01 and 70842–0120–01.”
New Technology
Melinta Therapeutics, Inc.’s application for new technology add-on payments for VABOMERE™ for FY 2019 was approved by CMS. The maximum new technology add-on payment for cases involving the use of VABOMERE™ for FY 2019 is $5,544.
What is VABOMERE™ (Meropenem-vaborbactam)?
VABOMERE™ is a combination product containing meropenem and vaborbactam. This drug is indicated for treating adult patients diagnosed with complicated urinary tract infections (cUTIs), including pyelonephritis caused by the following susceptible microorganisms: Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae species complex.
Issue
There is no unique ICD-10-PCS procedure code for VABOMERE™ for FY 2019 leaving hospitals with no way to uniquely identify the use of VABOMERE™ on an inpatient claim.
How to identify the use of VABOMERE™ on an Inpatient Claim
CMS revised their policy to allow the use of an alternative code set to identify an oral medication when there is no inpatient procedure code for purposes of new technology add-on payments in the FY 2013 IPPS Final Rule. Specifically, they adopted the National Drug Code (NDC) as an alternative code set to identify the use of DIFICID™ effective for discharges on or after October 1, 2012.
While VABOMERE™ is administered by IV infusion and not orally, CMS acknowledges that “it is the first approved new technology aside from an oral drug with no uniquely assigned inpatient procedure code” and believes for purposes of identifying the use of VABOMERE™ this is a similar circumstance to the use of DIFICID™.
For FY 2019, cases eligible for the FY 2019 new technology add-on payments will be identified by the NDC code 65293-0009-01 (VABOMERE™ Meropenem-Vaborbactam Vial) or NDC code 70842-0120-01. Providers must code the NDC in data element LIN03 of the 837i Health Care Claim Institutional form in order to receive the new technology add-on payment for procedures involving the use of VABOMERE™.”
Who Needs to Know this Information?
Your hospital Pharmacy should be made aware of this information so they can collaborate with your Billing Office to ensure you receive the add-on payment for eligible claims.
Resources
Billing guidance can be found on page 49837 of the October 3, 2018 Final Rule Correction Notice published in the Federal Register which can be accessed from the CMS FY 2019 IPPS Final Rule Homepage at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2019-IPPS-Final-Rule-Home-Page.html.
Additional information about VABOMERE™ can be found on the Melinta Therapeutics, Inc. website at http://www.vabomere.com/.
Beth Cobb
One frustration of healthcare workers is that they spend almost as much time on documentation and complying with burdensome regulations as they do taking care of patients. The current government Administration has promised to provide some relief by removing unnecessary, obsolete or excessively burdensome Medicare compliance requirements for healthcare facilities. To this end, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule on September 17, 2018 reforming some Medicare regulations to reduce the amount of time and resources that healthcare facilities have to spend on CMS-mandated compliance activities that do not improve the quality of care. According to the CMS Administrator, this will allow hospitals and healthcare professionals to focus on their primary mission of treating patients.
Here are some of the proposals to change the Medicare Conditions of Participation (CoP) that affect hospitals either directly or indirectly:
- Hospital systems could elect to have one unified and integrated Quality Assessment and Performance Improvement (QAPI) program for all of its member hospitals instead of individual programs for each hospital. Such a program must be in compliance with State and local laws, consider the unique circumstances and differences of the member hospitals, and be able to address needs and issues specific to each hospital.
- Hospitals could establish a medical staff policy that would allow a pre-surgery/pre-procedure assessment for an outpatient in certain circumstances, instead of a comprehensive medical history and physical examination (H&P). The assessment would have to be documented in the patient’s medical record. The hospital’s policy would have to consider medical factors (such as the patient’s diagnosis and other conditions, type of surgery, etc.), nationally recognized guidelines and standards of practice, and applicable state and local health and safety laws.
- Like the above described unified quality program, the rule also proposes allowing a unified and integrated infection control program for multi-hospital systems. The same considerations of the differences and unique needs of each hospital apply for a unified infection control program as they do for the unified quality program.
- Hospitals and other facilities are required by law to have processes for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. This requirement is not changed but the requirement to document participation in collaborative and cooperative planning efforts, including documentation of contact efforts, is proposed to be eliminated. There are also proposals to provide flexibility in the time frame of review of Emergency Preparedness plans, decrease the required frequency of training to every two years instead of annually, and allow flexibility in the types of testing exercises for both inpatient and outpatient exercises.
- Remove the requirement for hospitals to perform autopsies in all cases of unusual deaths and of medical-legal and educational interest. Hospitals would follow State laws regarding such medical-legal requirements.
There are also proposals that address changes to critical access hospitals (CAHs) annual review of policies and procedures, hospital and CAH swing-bed requirements, requirements for transplant centers, and clarification of who is allowed to document progress notes in a psychiatric hospital. Other proposals address different types of providers.
One proposal for ambulatory surgery centers (ASCs) may be of interest to hospitals. CMS is proposing to remove the requirement that ASCs have a transfer agreement with a hospital and that the ASC surgeons have admitting privileges at a hospital. CMS sites hospitals’ refusals to sign such agreements and the EMTALA requirements that hospitals must treat emergencies as reasons why the current requirements do not affect patient safety and therefore are no longer needed.
If you would like more information, please refer to the proposed rule, the press release, and/or the CMS Fact Sheet.
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
Healthcare Provider Taxonomy Codes (HPTCs) October 2018 Code Set Update
October 2018 Integrated Outpatient Code Editor (I/OCE) Specifications Version 19.3
October updates to the I/OCE.
Claim Status Category and Claim Status Codes Update
October 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Changes, new codes, and billing instructions for various OPPS payment policies.
Influenza Vaccine Payment Allowances - Annual Update for 2018-2019 Season
Annual Clotting Factor Furnishing Fee Update 2019
Announces the clotting factor furnishing fee for 2019 is $0.220 per unit.
International Classification of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)
A maintenance update of ICD-10 conversions and other coding updates specific to NCDs.
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – October 2018 Update - REVISED
Informs MACs of the October 2018 addition of new HCPCS codes, Q5108 (Injection, fulphila) and Q5110 (Nivestym). The codes are payable by Medicare effective with dates of service on or after July 12, 2018, for Q5108 and effective with dates of service on or after October 1, 2018, for Q5110.
OTHER MEDICARE TRANSMITTALS
Update to Chapter 15, Pub. 100-08, Certification Statement Policies
Modifications to certain provider enrollment certification statement policies, specifically, allowing upload provider enrollment certification statements using PECOS functionality.
Revisions to the Telehealth Billing Requirements for Distant Site Services – REVISED
Revised to correct the effective date of the GT modifier.
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).
MEDICARE SPECIAL EDITION ARTICLES
Intensity-Modulated Radiation Therapy (IMRT) Planning Services Editing
When IMRT is paid under the hospital OPPS, hospitals must remember that CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 (IMRT planning). You should not report these codes in addition to CPT code 77301, when provided prior to, or as part of, the development of the IMRT plan. The charges for these services should be included in the charge associated with CPT code 77301, even if the individual services associated with IMRT planning are performed on dates of service other than the date on which CPT code 77301 is reported.
MEDICARE RULES
Medicare and Medicaid Programs; Proposed Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction
A proposed rule to relieve burden on healthcare providers by removing unnecessary, obsolete or excessively burdensome Medicare compliance requirements for healthcare facilities.
Provisions in the proposed rule would, for example:
- Eliminate a duplicative requirement on transplant programs to submit data and other information more than once for “re-approval” by Medicare.
- Streamline hospital outpatient and ambulatory surgical center requirements for conducting comprehensive medical histories and physical assessments.
- Allow multi-hospital systems to have unified and integrated Quality Assessment and Performance Improvement programs for all of their member hospitals.
- Simplify the ordering process for portable x-rays and modernize the personnel requirements for portable x-ray technologists.
- Remove duplicative ownership disclosure requirements for Critical Access Hospitals.
OTHER MEDICARE UPDATES
Federal Register: Changes to the Low-Volume Hospital Payment Adjustment Under the IPPS
Announces changes to the payment adjustment for low-volume hospitals under the hospital IPPS for acute care hospitals for FY 2011-2017.
https://www.gpo.gov/fdsys/pkg/FR-2018-08-23/pdf/2018-18271.pdf
Updated Guidance to Hospitals and CAHs Concerning Swing Beds
CMS is providing updated guidance to surveyors for the special requirements for Hospital and CAH providers of long-term care services (LTC), also known as “swing beds”.
MEDICARE EDUCATIONAL RESOURCES
Diabetes Self-Management Training Accrediting Organizations Fact Sheet
CMS Provider Minute Video: The Importance of Proper Documentation — Reminder
Explain importance of proper documentation and how it affects items/services, claim payment, and medical review.
https://www.youtube.com/watch?v=10pmw4czf08&feature=youtu.be
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Provider Minute Video: The Importance of Proper Documentation
- Bill Correctly for Device Replacement Procedures
Medicare Preventive Services On-Line Educational Tool
Information on Medicare preventive services that includes:
- A link to the National Coverage Determination (NCD) webpage for the service, if it applies
- HCPCS/Current Procedural Terminology (CPT) codes
- International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes
- Coverage requirements
- Frequency requirements
- Medicare beneficiary liability
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