Knowledge Base Category -
Ambulance Inflation Factor for CY 2018 and Productivity Adjustment
The Calendar Year (CY) 2018 Ambulance Inflation Factor (AIF) for determining the payment limit for ambulance services is 1.1 percent.
Correction to Prevent Payment on Inpatient Information Only Claims for Beneficiaries Enrolled in Medicare Advantage Plans
Sets system edits to zero out payment on inpatient information only claims billed with condition codes 04 and 30 for Investigational Device Exemption (IDE) Studies and Clinical Studies Approved Under Coverage with Evidence Development (CED).
New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set- Aside Arrangements (NFMSAs) - RESCINDED
Clarifying Signature Requirements
Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies. Claim denials shall be limited to those instances in which signatures that are required by Medicare policies are flawed or missing.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R751PI.pdf
Clinical Laboratory Improvement Amendments of 1988 (CLIA); Fecal Occult Blood (FOB) Testing
Clarifies CLIA regulations that the waived test categorization applies only to non- automated fecal occult blood tests.
https://www.gpo.gov/fdsys/pkg/FR-2017-10-20/pdf/2017-22813.pdf
Calculating Interim Rates for Graduate Medical Education (GME) Payments to New Teaching Hospitals – REVISED
Re-issued to revise several policy statements and to address how to handle certain impacted claims.
New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set-Aside Arrangements (NFMSAs) – REPLACED
Removes provider education requirements from original transmittal.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1954OTN.pdf
Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs Final Rule
Revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2018.
https://www.gpo.gov/fdsys/pkg/FR-2017-11-13/pdf/2017-23932.pdf
Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018
Addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies to update payment systems to reflect changes in medical practice and the relative value of services, as well as changes in the statute. In addition, this final rule includes policies necessary to begin offering the expanded Medicare Diabetes Prevention Program model.
https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953.pdf
Implementation of the Award for the Jurisdiction Part A and Part B Medicare Administrative Contractor (JJ A/B MAC)
Announces CMS has awarded the JJ A/B MAC contract for the administration of the Part A and Part B Medicare fee-for-service claims in the states of Alabama (AL), Georgia (GA) and Tennessee (TN) to Palmetto GBA LLC.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1960OTN.pdf
Update to Pub 100-04, Chapter -18 Preventive and Screening Services -Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)
Adds ICD-10 diagnosis codes: F17.210 (Nicotine dependence, cigarettes, uncomplicated), F17.211 (Nicotine dependence, cigarettes, in remission), F17.213 (Nicotine dependence, cigarettes, with withdrawal), F17.218 (Nicotine dependence, cigarettes, with other nicotine-induced disorders), or F17.219 (Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders), for LDCT coverage.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3901CP.pdf
Billing Requirements for Ophthalmic Bevacizumab
Clarifies HCPCS code for billing ophthalmic bevacizumab.
Notification of the 2018 Dollar Amount in Controversy Required to Sustain Appeal Rights for an Administrative Law Judge (ALJ) Hearing or Federal District Court Review
ALJ hearing requests amount for 2018 will remain at $160. Federal District Court appeals amount will increase to $1,600 for 2018.
Accepting Payment from Patients with a Medicare Set-Aside Arrangement
Explains what a MSA is and explains why it is appropriate to accept payment from a patient that has a funded MSA.
CMS Hospital Value-Based Purchasing Program Results for Fiscal Year 2018
Fact Sheet describing VBP program and updates. Estimates the total amount available for value-based incentive payments for FY 2018 discharges will be approximately $1.9 billion.
Additional Appeals Settlement Option
CMS will make available an additional settlement option for providers and suppliers (appellants) with appeals pending at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council (the Council) at the Departmental Appeals Board.
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
NCD coding changes the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
CMS Posts RAC Review Topics
CMS has begun to post a list of review topics that have been proposed, but not yet approved, for RACs to review. These topics will be listed, on a monthly basis, on the Provider Resources page.
Partial Settlement of 2-Midnight Policy Court Cases
Provides instructions to Medicare Administrative Contractors (MACs) on how to ensure hospitals receive additional payments due to a partial settlement agreement regarding the 0.2 percent downward adjustment beginning in Fiscal Year ("FY") 2014.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1969OTN.pdf
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).
Annual Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
Provides the 2018 annual update to the list of Healthcare Common Procedure Coding System (HCPCS) codes used by Medicare systems to enforce consolidated billing of home health services.
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP), and PC Print Update
Updates the Remittance Advice Remark Codes (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs Medicare Shared System Maintainers (SSMs) to update Medicare Remit Easy Print (MREP) and PC Print.
Claim Status Category Codes and Claim Status Codes Update
MAC and shared systems changes will be made as necessary as part of a routine release to reflect applicable changes such as retirement of previously used codes or newly created codes.
Therapy Cap Values for Calendar Year (CY) 2018
For physical therapy and speech-language pathology combined, the CY 2018 cap is $2,010. For occupational therapy, the CY 2018 cap is $2,010.
New Positron Emission Tomography (PET) Radiopharmaceutical/Tracer Unclassified Codes
CMS has created two new PET radiopharmaceutical unclassified tracer codes that can be used temporarily pending the creation/approval/implementation of permanent CPT codes that would later specifically define their function: A9597 - Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified; A9598 – Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified.
2018 Medicare Parts A & B Premiums and Deductibles
On November 17, 2017, the Centers for Medicare & Medicaid Services (CMS) released the 2018 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs. The standard monthly premium for Medicare Part B enrollees will be $134 for 2018, the same amount as in 2017. The annual deductible for all Medicare Part B beneficiaries will be $183 in 2018, the same annual deductible in 2017. The Medicare Part A annual inpatient hospital deductible that beneficiaries pay when admitted to the hospital will be $1,340 per benefit period in 2018, an increase of $24 from $1,316 in 2017.
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-17.html
Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
Provides the quarterly update of HCPCS codes used for HH consolidated billing effective April 1, 2018.
Calculating Interim Rates for Graduate Medical Education (GME) Payments to New Teaching Hospitals
Provides instructions to the MACS on calculating interim rates for Graduate Medical Education (GME) payments to new teaching hospitals.
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2017 Update
Recurring quarterly update to HCPCS code set – created new modifier ZC for use with biosimilars manufactured by Merck/Samsung Bioepis, such as Infliximab.
Updates to Medicare’s Cost Report Worksheet S-10 to Capture Uncompensated Care Data
Provides additional guidance to 1886(d) hospitals to ensure appropriate reporting of uncompensated care costs and to achieve proper Medicare reimbursement. Summarizes revisions and clarifications to the instructions for the Worksheet S-10 of the Medicare cost report.
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edits, Version 24.0, Effective January 1, 2018
Recurring quarterly updates of CCI edits.
Accepting Payment from Patients with a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA), a Liability Insurance Medicare Set-Aside Arrangement (LMSA), or a No-Fault Insurance Medicare Set-Aside Arrangement (NFMSA) - RESCINDED
Rescinded October 3, 2017
Implementing the Remittance Advice Messaging for the 20 Hour Weekly Minimum for Partial Hospitalization Program Services – REISSUE
Re-issued on October 3, 2017, to confirm that its content remains valid even though Special Edition Article SE1607 was rescinded. Message on remittance reminding providers that PHP patients require a minimum of 20 hours of PHP services per week, in accordance with the plan of care.
Medicare Appeals; Adjustment to the Amount in Controversy (AIC) Threshold Amounts for Calendar Year 2018
Federal Register Notice – The calendar year 2018 AIC threshold amounts are $160 for ALJ hearings and $1,600 for judicial review.
https://www.gpo.gov/fdsys/pkg/FR-2017-09-29/pdf/2017-20883.pdf
January 2018 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Quarterly update to drug pricing. OPPS hospitals are paid ASP + 6% for separately paid drugs (both pass-through and non-pass-through drugs).
Transition to New Medicare Numbers and Cards
Factsheet telling the why, when, and how to be ready for the new cards.
Clarification Regarding the Use of Control Materials as Calibrators to Determine Test Cut-off Values (Laboratories)
Memorandum to State Survey Agency Directors clarifying information concerning laboratory controls and calibration materials.
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2018
Quarterly updates to the national coverage policies for certain laboratory tests. There is a link within the article to a spreadsheet of all the changes – deletions and additions.
Clinical Laboratory Fee Schedule Not Otherwise Classified, Not Otherwise Specified or Unlisted Service or Procedure Code Data Collection
Instructs providers to include the laboratory test name or short description in Field 19 when billing an unlisted laboratory test code on a 1500 claim form. Also, laboratory “reporting entities” must report private payor payment rates and volumes for unique tests reported with an unlisted code.
2018 Medicare Electronic Health Record (EHR) Incentive Program Payment Adjustment Fact Sheet for Hospitals
Fact sheet on the EHR payment adjustments for eligible hospitals.
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-10-10.html
Notice of New Interest Rate for Medicare Overpayments and Underpayments -1st Qtr. Notification for FY 2018
The certified interest rate effective October 18, 2017 for Medicare over- and under-payment is 9.750%.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R295FM.pdf
Defending Medical Review Decisions at Administrative Law Judge (ALJ) Hearings
Updates Medicare Program Integrity Manual due to recent changes in the Office of Medicare Hearings and Appeals process, such as restrictions on the number of contractors able to participate during oral testimony and the adoption of the witness role for those cases in which additional support may be sought.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R748PI.pdf
Medicare Quarterly Provider Compliance Newsletter – October 2017
Provide education on how to avoid common billing errors and other erroneous activities when dealing with the Medicare Fee-For-Service (FFS) Program. This quarter’s newsletter addresses Arthroscopic Rotator Cuff Repair (Physicians), CERT errors for Outpatient Hospital Services, and a DME item.
Prohibition on Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program – REVISED
Revised October 18, 2017 to indicate the Provider Remittance Advice and Medicare Summary Notice identifies the QMB status of beneficiaries and exemption from cost-sharing for Part A and B claims processed on or after October 2, 2017. It also recommends how providers can use these and other upcoming system changes to promote compliance with QMB billing requirements.
Fiscal Year (FY) 2018 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes - REVISED
Updates to some financial information, tables, files, and lists.
American Hospital Association (AHA) Letter to Office of Inspector General (OIG)
The AHA request to OIG to implement actions to address fundamental flaws and inaccuracies in the OIG hospital compliance reviews.
http://www.aha.org/advocacy-issues/letter/2017/171002-let-hatton-cms-hospital-compliance-reviews.pdf
Hurricane Nate and Medicare Disaster Related Alabama, Florida, Louisiana and Mississippi Claims
Describes CMS authorized waivers for providers affected by Hurricane Nate.
If you deal in the world of Medicare Parts A and B and you live in the state of Alabama, Georgia, or Tennessee, there was big news for you in early September. On September 7, 2017, CMS awarded Palmetto GBA (Palmetto) a new contract for the administration of Medicare Part A and Part B Fee-for-Service (FFS) claims in the states of Alabama, Georgia, and Tennessee (A/B MAC Jurisdiction J). Jurisdiction J is currently handled by Medicare Administrative Contractor (MAC) Cahaba GBA.
So if you are a provider in Jurisdiction J, what do you need to know about this change?
The A/B MAC Jurisdiction J Palmetto Contract…
- Will provide Medicare services to more than 400 hospitals, 52,000 physicians, and 2.5 million Medicare beneficiaries.
- Has a total estimated value of $274.6 million.
- Includes a base year and four option years, for a maximum duration of five years.
- Includes the following duties for Palmetto – processing and paying Medicare Part A and Part B provider claims, enrolling and auditing Medicare providers, educating providers on Medicare coverage requirements, and other duties.
Palmetto GBA …
- Is currently the A/B MAC for Jurisdiction M, which includes the states of North Carolina, South Carolina, Virginia, and West Virginia.
- Is also the MAC for Home Health and Hospice providers in Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee and Texas.
- Will be opening an office in Birmingham, AL; Palmetto will also perform the contract from offices in Columbia, Florence, and Camden, SC.
- Palmetto’s website - palmettogba.com
The Transition and Resources
- The implementation effective date for Part A in all 3 states is January 29, 2018
- The implementation effective date for Part B is February 26, 2018.
- CMS and Palmetto anticipate a smooth transition, with few, if any, service issues for Medicare beneficiaries and providers.
- Palmetto GBA’s goal is to communicate early, often and continually throughout the implementation to ensure all stakeholders, providers, medical and hospital associations and Members of Congress, are well-informed with consistent, open and clear information.
- Palmetto's Transition Website site includes general information, FAQs, and Outreach and Education
- Palmetto prefers questions concerning the transition be submitted via Twitter or Facebook (see Palmetto Transition FAQs)
- Face-to-Face JJ Implementation Workshops are planned for the end of October and the beginning of November. As soon as the dates and locations are determined, they will be advertised on the JJ website for registration.
- There are already educational videos on the Palmetto Transition Education and Outreach webpage about Palmetto GBA and some of their eServices features such as eUtilization, eAudits, eCBR (comparative billing reports), and Managing Your Medicare Information.
What Providers Need to Do
- Register for listserv email updates from Palmetto GBA. To register simply select listserv at the top of the Palmetto's Transition Website
- Visit this website for Medicare program information and updates. Palmetto GBA’s website is continually updated with the most current information.
- Read the MMP Wednesday@One newsletter for future information about Palmetto and the Jurisdiction J transition.
Debbie Rubio
Growing up in the south, I remember being told that summer is mosquito season. What I found in writing this article is that it’s more about the temperature levels. Specifically, when temperatures reach a consistent 50°F mosquito eggs begin hatching and mosquito season begins. So, in more temperate parts of the nation, mosquitoes can be present year-round. Here in my home state of Alabama the mosquito season typically begins in early March.
I also learned that there are over 3,000 different species of mosquitoes throughout the world; currently 176 of these species has been recognized in the United States. Today, we are focusing on just one group of mosquito, Aedes mosquitoes that can transmit the Zika virus.
About the Virus
The Zika Virus was first discovered in 1947 in the Zika Forest of Uganda. The first human cases of the virus were detected in 1952 and since outbreaks have been reported in tropical Africa, Southeast Asia, and the Pacific Islands. The disease is transmitted by Aedes mosquitoes who also transmit three other vector-borne diseases (dengue, chikungunya and yellow fever).
The Centers for Disease Control (CDC) indicates that most infected people are asymptomatic. When a person is symptomatic, common symptoms of the virus normally lasts for 2-7 days and can include:
- Acute onset of fever,
- Maculopapular rash,
- Headache,
- Muscle and joint pain, and
- Conjunctivitis.
The World Health Organization (WHO) notes two serious complications reported by Brazil:
- July 2015: Brazil reported an association between the virus and Guillain-Barre syndrome.
- October 2015: Brazil reported an association between the virus infection and microcephaly.
On February 1, 2016 the WHO declared the Zika virus a Public Health Emergency of International Concern (PHEIC) and since then has been posting weekly Zika Situation Reports. The last report posted at the time of this article was June 23, 2016. Key notes of concern from the June 23rd Summary includes:
- As of June 22, 2016, 61 countries and territories report continuing mosquito-borne transmissions of which:
- 47 countries are experiencing a first outbreak of the virus since 2015 with ongoing transmissions by mosquitoes.
- Ten countries have reported evidence of person-to-person transmission of the virus noted to probably be via a sexual route.
- As of June 22, 2016, microcephaly and other central nervous system (CNS) malformations potentially associated with the virus or suggestive of congenital infection have been reported by twelve countries or territories.
- As of June 9th, the CDC has reported three live born infants with birth defects and three pregnancy losses with birth defects with laboratory evidence of possible Zika virus infection.
- 13 Countries and territories worldwide have reported an increase incidence of Guillain-Barre syndrome (GBS) and/or laboratory confirmation of a Zika virus infection among GBS cases.
Medicare to Cover Diagnostic Testing for Zika Virus
CMS has released MLN Matters Article SE1615 titled Medicare Coverage of Diagnostic Testing for Zika Virus. Specific Provider Action Needed includes:
- Informing the public that Medicare covers testing under Medicare Part B “as long as the clinical diagnostic laboratory test is reasonable and necessary for the diagnosis or treatment of a person’s illness or injury,”
- As currently there are no HCPCS codes for testing of the Zika virus, laboratories furnishing the Zika tests should contact their Medicare Administrative Contractors (MACs) for guidance on appropriate billing codes to use on the claims; and
- Labs should provide “resources and cost information as may be requested by the MACs in order for the MACs to establish appropriate payment amounts for the tests.”
ICD-10-CM Coding for Zika
The Zika Virus was discussed during the March 9-10, 2016 ICD-10 Coordination and Maintenance Committee Meeting. ICD-10-CM currently classifies the virus to code A92.8, Other specific mosquito-borne virus.
In December 2015 the WHO noted the need for a separate code for the Zika Virus to allow for tracking of cases. The WHO proposed a new code for the Zika virus (A92.5). To be consistent with the planned WHO ICD-10 update, effective October 1, 2016 ICD-10-CM will include the addition of the following:
Chapter 1 – Certain Infectious and Parasitic Diseases (A00-B99)
A92 – Other Mosquito-borne viral fevers
New Code: A92.5 – Zika virus disease
Zika virus fever
Zika virus infection
Zika, NOS
Prevention
The American Mosquito Control Association (AMCA) is an association “dedicated to providing leadership, information and education leading to the enhancement of public health and quality of life through the suppression of mosquitoes.” In fact, this past week of June 26 – July 2nd was National Mosquito Control Awareness Week 2016. In a Press Release template, the AMCA® reminds the public to practice the THREE D's of Mosquito Prevention and Protection:
- Drain: Empty out water containers at least once per week
- Dress: Wear long sleeves, long pants, and light-colored, loose-fitting clothing, and
- Defend: Properly apply an approved repellant such as DEET, picaridin, IR3535 or oil of lemon-eucalyptus.
Beth Cobb
Dilemma:
A patient was recently admitted to an acute care hospital diagnosed with an infection from a vascular access device. The patient was then discharged from the acute care hospital and admitted to a long-term acute care hospital (LTACH) to continue antibiotics for the infection. What 7th character would be assigned for the principal diagnosis to the LTACH, initial encounter (A) or subsequent encounter (D)?
Solution:
The principal diagnosis for the LTACH admission is (T82.7XXA) for Infection/Inflammatory Reaction due to Other Cardiac/Vascular Device, Initial Encounter. The patient is still receiving active treatment for the infection of the vascular device so the 7th character is an A. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.
Information Source(s):
- ICD-10-CM Official Guidelines for Coding and Reporting, Chapter 19, Application of 7th Characters
- 1Q, Coding Clinic, 2015, under the heading, Applying the 7th Character for Continued Treatment in Other Care Settings
Debbie Rubio
On April 1st, President Obama signed into law the Protecting Access to Medicare Act of 2014. Per a White House Press Secretary release this new law “averts cuts to Medicare physician payments that will go into effect on April 1, 2014, under the current-law “sustainable growth rate” system, to extend other health-related provisions set to expire, and to make other changes to current-law health provisions.” In addition to averting cuts to physician payments, this law includes additional “Medicare Extenders” and “Other Health Provisions.” But before looking at some of the more significant topics within the law, it is interesting to note how quickly this bill was presented, voted on and became law.
- March 26, 2014: Representative Joe Pitts (R-PA), Chairman, Energy and Commerce Subcommittee on Health introduced H.R. 4302 the Protecting Access to Medicare Act of 2014.
- March 27, 2014: The House voted by a voice vote and approved the bill. This vote was under special rules that provided for no amendments, limited debate and only needed a two-thirds majority votes.
- March 31, 2014: The United States Senate passed the bill with a vote of 64 YEAs, 35 NAYs and 1 Not Voting.
April 1, 2014: The Act was signed into law by President Obama signed the Protecting Access to Medicare Act of 2014 into Law.
Spotlight on Extensions and Health Provisions in the Law:
Section 101: Physician Payment Update: This section provides for a 0.5 percent update for claims with dates of service on or after January 1, 2014, through December 31, 2013. Further, it provides a zero percent update to the 2015 Medicare Physician Fee Schedule (MPFS) through March 31, 2015.
Section 103: Extension of Therapy Cap Exception Process: This section extends the exceptions process for outpatient therapy caps through March 31, 2015. When a provider requests an exception to the cap for medically necessary services they must submit the KX modifier on their claim. This law extends the application of the caps, exceptions process, and threshold for therapy services provided in a hospital outpatient department (ODP).
Therapy caps for 2014:
- Occupational Therapy (OT) cap is $1,920
- Physical Therapy (PT) and Speech-Language Pathology Services (SLP) combined is $1,920
Additional information regarding therapy caps can be found on the CMS Therapy Cap webpage as well as Chapter 5, Section 10.3 in the Medicare Claims Processing Manual.
Section 106: Extension of the Medicare-Dependent Hospital (MDH) Program: This program provides enhanced payment to small rural hospitals where Medicare beneficiaries makes up a significant percentage of inpatient days or discharges. This provision extends the program through March 31, 2015.
More information about MDH Hospitals can be found in the Acute Care Hospital Inpatient Prospective Payment System Fact Sheet. Specific criteria to be designated a MDH Hospital includes:
- It is rural (located in a rural area);
- It has 100 or fewer beds during the cost reporting period;
- It is not also classified as a Sole Community Hospital (SCH); and
- At least 60 percent of its inpatient days or discharges were attributable to Medicare Beneficiaries entitled to Part A during the hospital’s cost reporting period.
Section 111: Extension of Two-Midnight Rule:
For hospital staff closely involved in trying to implement the Two-Midnight Rule, I felt it was important to provide you with the exact language in the bill.
“(a) CONTINUATION OF CERTAIN MEDICAL REVIEW ACTIVITIES.— The Secretary of Health and Human Services may continue medical review activities described in the notice entitled ‘‘Selecting Hospital
Claims for Patient Status Reviews: Admissions On or After October 1, 2013’’, posted on the Internet website of the Centers for Medicare & Medicaid Services, through the first 6 months of fiscal year
2015 for such additional hospital claims as the Secretary determines appropriate. (b) LIMITATION.—The Secretary of Health and Human Services shall not conduct patient status reviews (as described in such notice) on a post-payment review basis through recovery audit contractors under section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)) for inpatient claims with dates of admission October 1, 2013, through March 31, 2015, unless there is evidence of systematic gaming, fraud, abuse, or delays in the provision of care by a provider of services (as defined in section 1861(u) of such Act (42 U.S.C. 1395x(u))).”
What does this mean for hospitals?
- The Medicare Administrative Contractor (MAC) Probe and Educate program has now been extended for a fourth time through March 31, 2015.
- Recovery Audit Contractors “shall not conduct patient status reviews on a post-payment review basis” for inpatient claims with dates of service October 1, 2013 through March 31, 2015. It is important to remember that on February 18th CMS announced that current RAC activity is winding down during the new contract procurement round.
- Hospitals should take advantage of this additional time to continue to educate staff and fine tune your processes.
Section 212: Delay in Transition for ICD-9 to ICD-10 Code Sets
“The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations.”
This is a significant delay for everyone that has been proactively planning and providing education for an October 1, 2014 transition to the ICD-10 Code Sets. MMP plans to continue to provide I-10 Corner articles and encourages all to not look at this as a setback but as an opportunity to provide more training to your staff and test the readiness of your computer systems.
Section 221: Medicaid DSH
This law delays reductions in payments to Disproportionate Share Hospitals (DSH) by a year and then makes additional reductions through 2024.
There are still quite a few extensions and provisions not discussed in this article. MMP encourages those interested to review the Protecting Access to Medicare Act of 2014 in its entirety.
Beth Cobb
It has been just over three years since the Affordable Care Act (ACA) was signed into law on March 23, 2010. This slide provided by the Kaiser Family Foundation Health Tracking Polls, polled people on their view of the health reform bill based on what they know about it. As you can see, there are very mixed views.
To test what you know about the health reform law you can go to the Kaiser Health Reform quiz at this link: http://healthreform.kff.org/quizzes/health-reform-quiz.aspx
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Beth Cobb
This week we would like to acknowledge Cardiac Rehab Week. Cardiac Rehabilitation Week was initiated by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) to focus national attention on cardiac rehabilitation’s contribution to the improvement of the health and physical performance of individuals at risk for heart disease and/or those individuals diagnosed with heart disease or dysfunction. MMP, Inc. expresses our appreciation to the dedicated individuals who work with patients, physicians, and other health care providers to make us all “heart healthier”. And to assist cardiac rehab providers, we offer the following guidance on Medicare coverage of Cardiac Rehabilitation services.
Make sure the cardiac rehabilitation services you are providing meet all of Medicare’s requirements in order to ensure appropriate reimbursement. Palmetto GBA, the Part A MAC for Jurisdiction 11, has conducted service specific complex reviews of cardiac rehab services in South Carolina, North Carolina, Virginia, and West Virginia. In the last round of reviews, denial rates, although continuing to decrease, were still between 48 – 64%.
In addition to lack of timely submission of medical records and services not documented, the findings demonstrated the following denial reasons:
- Cardiac Rehab Not Warranted for Diagnosis - Medicare covers cardiac rehabilitation items and services for patients who have experienced one or more of the following:
- An acute myocardial infarction within the preceding 12 months; or
- A coronary artery bypass surgery; or
- Current stable angina pectoris; or
- Heart valve repair or replacement; or
- Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
- A heart or heart-lung transplant.
- Cardiac Rehab Session Did Not Include the Required Services - Cardiac rehabilitation programs must include the following components:
- Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished;
- Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs;
- Psychosocial assessment;
- Outcomes assessment; and
- An individualized treatment plan detailing how components are utilized for each patient.
- Physician Must Be Readily Available - All settings must have a physician immediately available and accessible for medical consultations and emergencies at all time items and services are being furnished under the program. This provision is satisfied if the physician meets the requirements for the direct supervision for hospital outpatient therapeutic services.
Also, providers need to be aware of the frequency limitations for Cardiac Rehab services. Cardiac Rehab services are limited to a maximum of two 1-hour sessions per day for up to 36 sessions over up to 36 weeks with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor.
More information concerning Cardiac Rehab and Medicare coverage and billing requirements can be found at:
Debbie Rubio
How many times have you heard someone say that complete and accurate medical record documentation and quality improvement efforts are vitally important because they impact what is being publically reported about your hospital? Well, it’s true. But who exactly is looking at you?
The Centers for Medicare and Medicaid Services (CMS) has provided an educational tool for hospitals titled Contractor Entities At A Glance: Who May Contact You About Specific Centers for Medicare & Medicaid Services (CMS)
- Program Integrity Contractors (i.e. Recovery Auditors, Zone Program Integrity Contractors (ZPICs), Comprehensive Error Rate Testing Review Contractor (CERT RC) and Medicaid Integrity Contractors (MICs)),
- Quality Contractors (i.e. Quality Improvement Organizations (QIOs)),
- Specialized Work Contractors (i.e. Medicare Coordination of Benefits Contractor (COBC)),
- Claims Administrative Contractors (i.e. MACs, DME MACs); and
- Appeals Contractors and Entities (i.e. Qualified Independent Contractors (QIC) and Administrative Law Judge (ALJ).
While this is a great tool for hospitals to understand who may contact them, what sources are available for the public to use to select a physician, a hospital, a nursing home, etc.?
In June of 2011 the Robert Wood Johnson Foundation launched a
National Directory that is a compilation of state, federal, hospital and health plan quality data from across the country. The Foundation indicates that “our directory provides access to publicly available, free reports with information about the process of delivery care (for example, did patients get all the recommended care?), actual outcome for patients (for example, did patients die or have to return to the hospital?), what patients said in surveys about their experience with physicians or hospitals, and/or cost.” In the 16 months since the Directory was launched the list of public reports has increased from 224 separate sites to 258.
Below is a much smaller list of sites compiled by MMP, Inc. to provide you with an idea of who is publicly reporting data about your hospital and information about each report.
We believe that focused efforts on complete and accurate medical record documentation, quality improvements efforts and understanding what is being publicly reported about your efforts are positive steps towards clients embracing the shift in health care away from the traditional Fee-for-Service model towards payment for Quality Care as evidenced by current initiatives such as the 30 Day Readmission Reduction Program, Value-Based Purchasing and Accountable Care Organizations.
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