Knowledge Base Category -
CMS released MLN Matters Article MM11181 titled “Billing for Part B Hospital Inpatient Services” on March 22, 2019. This is not a new rule at all, but has been around since 2013. In the 2014 Inpatient Prospective Payment System (IPPS) Final Rule CMS-1599-R, effective October 1, 2013, CMS first allowed the billing of certain Part B services when an inpatient hospital admission is determined to not be reasonable and necessary for payment under Medicare Part A. Prior to this rule change, the billing of Part B inpatient services on a 12x type of bill (TOB) was limited to those occasions when the Medicare beneficiary did not have Part A coverage or the Part A benefits were exhausted.
The new policy specifically stated, “Medicare will allow payment under Part B of all hospital services that were furnished and would have been reasonable and necessary if the patient had been treated as a hospital outpatient, rather than admitted to the hospital as an inpatient.” The determination that the patient did not meet inpatient criteria could have been from 1) a denial by Medicare or 2) the result of a hospital “self-audit” after the patient was discharged. There are rules for the hospital self-audit.
- It must follow Medicare Conditions of Participation UR guidelines (42 CFR 428.30);
- It must be made by a physician member of the UR committee if the attending physician concurs, or by 2 physician members of the UR committee if the attending does not concur;
- The attending physician must be consulted; and
- The patient must be notified of the decision in writing within 2 days.
CMS also expanded what could be billed on a 12x TOB under Part B for these “reasonable and necessary inpatient admission denials” to include surgeries, drugs and therapeutic services such as coronary and peripheral interventions. Services requiring an outpatient status such as observation services and ED visits, and routine inpatient services cannot be billed under Part B inpatient billing. Note that the routine inpatient services include drug administrations, blood transfusions, and nebulizer treatments provided by floor nurses and should not be reported on a Part B inpatient claim. CMS provides a list of revenue codes that should not be submitted on a “reasonable and necessary inpatient denial” 12x TOB in section 240.1 of chapter 4 of the Medicare Claims Processing Manual. When a revenue code can be sometimes covered and sometimes not covered, providers should use Medicare guidance and the HCPCS code to determine if the service is covered.
If the “reasonable and necessary inpatient denials” Part B rebilling rule is six years old, what was the purpose of this latest MLN article? Again, CMS did not really change any rules, but added verbiage to the Claims Processing Manual clarifying the need for a Part A claim prior to submitting the Part B claim. In order to submit a Part B 12x claim after a hospital self-audit, the hospital must:
- Submit a Part A claim indicating that the provider is liable under section 1879 of the Act for the cost of the Part A services. This is a no-pay inpatient claim, type of bill 110. If the hospital has already submitted a regular inpatient claim (111 TOB), it must adjust the Part A claim to make the provider liable.
- The Part B 12x type of bill may be submitted for these “reasonable and necessary inpatient denials” only after the Part A claim is denied or a no-pay claim is submitted.
Also, the Part B inpatient claim is subject to the timely filing requirements described in the Medicare Claims Processing Manual, Chapter 1, Section 70.
This new MLN Matters Article (MM11181) also makes some modifications to the list of revenue codes that are not allowed on a 12x TOB for “other circumstances.” These circumstances would be for Medicare patients who are not entitled to benefits under Part A, have exhausted their Part A benefits, or receive services not covered under Part A. Part B inpatient claims for these circumstances restrict the types of services that can be billed much more than the “reasonable and necessary inpatient denials” Part B rebilling.
For more information about Part B Inpatient billing, see sections 240.1 and 240.2 of Chapter 4 of the Medicare Claims Processing Manual and sections 10.1 and 10.2 of Chapter6 of the Medicare Benefits Policy Manual. And remember for Part B rebillling, it is always A before B.
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
April 2019 Quarterly ASP Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)
NCD coding changes as the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Healthcare Provider Taxonomy Codes (HPTCs) April 2019 Code Set Update
OTHER MEDICARE TRANSMITTALS
Processing Veterans Administration (VA) Inpatient Claims Exempt from Present on Admission (POA) Reporting
The HAC-POA payment provision required by the Deficit Reduction Act of 2005 (DRA) applies only to Inpatient Prospective Payment System (IPPS) hospitals. Therefore, VA hospitals are exempt from reporting POA and End of POA Indicators.
Updates to Reflect Removal of Functional Reporting Requirements and Therapy Provisions of the Bipartisan Budget Act of 2018
Updates both the Medicare Benefit Policy Manual and Medicare Claims Processing Manual to reflect recent policy revisions including: (a) the repeal of the application of the outpatient therapy caps and the retention of the therapy cap amounts as thresholds of incurred expenses above which claims must include a modifier to confirm services are medically necessary as shown by medical record documentation; and, (b) the discontinuation of the functional reporting requirements.
Ensuring Organ Acquisition Charges Are Not Included in the Inpatient Prospective Payment System (IPPS) Payment Calculation
To prevent potential overpayments, Medicare’s Fiscal Intermediary Shared System (FISS) will deduct organ acquisition charges billed with revenue codes 081X from the total covered charges prior to sending an inpatient Type of Bill (TOB) 11X claim to the IPPS pricer for any date of service processed on or after July 1, 2019.
Revising the Remittance Advice Messaging for the 20-Hour Weekly Minimum for Partial Hospitalization Program Services
Common Working File (CWF) Provider Queries National Provider Identifier (NPI) Verification
The Common Working File (CWF) will require verification of the NPI similar to the HETS when Medicare Part A providers request Medicare beneficiary eligibility and entitlement data via the CWF provider inquiry screens.
Processing Instructions to Update the Standard Paper Remit (SPR)
Instructs MACs to update their systems to ensure that SPRs mailed after July 1, 2019, mask the Health Insurance Claim Number (HICN), so the Social Security Number (SSN) does not show.
Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System
Makes the changes required to send Additional Documentation Request (ADR) letters to participating providers via the (esMD) system. A CR to effectuate the exchange of ADR letters to registered providers via the esMD system will be released at a later date.
Update to Mammography Editing
Modifies existing editing to ensure only revenue codes 0401, 0403, 0520, 0521, 096, 097, or 098 are billed on claims containing mammography codes 77065, 77066, or 77067.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4225CP.pdf
Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)
Effectuates changes to the SNF Prospective Payment System (PPS) that were finalized in the FY 2019 SNF PPS Final Rule (83 FR 39162).
Local Coverage Determinations (LCDs) – REVISED
Multiple revisions of this transmittal that changes the LCD process.
Modification of the MCS Claims Processing System Logic for Modifier 59, XE, XS, XP, and XU Involving the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Column One and Column Two Codes
Medicare will allow modifiers 59, XE, XS, XP, or XU on column one and column two codes to bypass the edit.
Update to the Internet-Only-Manual (IOM) Publication (Pub.) 100-04, Chapter 32, Section 12.1
Removes diagnosis codes from and adds diagnosis codes to the list of valid diagnosis codes for Counseling to Prevent Tobacco Use.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4237CP.pdf
MEDICARE COVERAGE
Update to Intensive Cardiac Rehabilitation (ICR) Programs
Effective February 9, 2018, coverage in an ICR is expanded to include stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35 percent or less and New York Heart Association (NYHA) Class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)—Clarification of Payment Rules and Expansion of International Classification of Diseases Tenth Edition (ICD-10) Diagnosis Codes
CMS proposes Coverage with Evidence Development for Chimeric Antigen Receptor (CAR) T-cell Therapy
Decision Memo for Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD) (CAG-00313R2)
CMS will cover FDA approved vagus nerve stimulation (VNS) devices for treatment resistant depression (TRD) through Coverage with Evidence Development (CED) when offered in a CMS approved, double-blind, randomized, placebo-controlled trial with a follow-up duration of at least one year with the possibility of extending the study to a prospective longitudinal study when the CMS approved, double-blind, randomized placebo-controlled trial has completed enrollment, and there are positive interim findings.
National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs) – REVISED
Implementation date changed from February 26, 2019 to March 26, 2019.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R213NCD.pdf
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Medicare Hospital Claims: Avoid Coding Errors
- DME Proof of Delivery Documentation Requirements
OTHER MEDICARE UPDATES
New App Displays What Original Medicare Covers
Allows people with Original Medicare, caregivers and others to quickly see whether Medicare covers a specific medical item or service.
https://www.cms.gov/newsroom/press-releases/new-app-displays-what-original-medicare-covers
Emergency Triage, Treat, and Transport (ET3) Model
A voluntary, five-year payment model that will pay participating ambulance suppliers and providers to 1) transport an individual to a hospital emergency department (ED) or other destination covered under the regulations, 2) transport to an alternative destination (such as a primary care doctor’s office or an urgent care clinic), or 3) provide treatment in place with a qualified health care practitioner, either on the scene or connected using telehealth.
https://www.cms.gov/newsroom/fact-sheets/emergency-triage-treat-and-transport-et3-model
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
As you may be aware by now, on January 8, 2019 Medicare issued MLN Matters Article SE19002, “Total Knee Arthroplasty (TKA) Removal from the Medicare Inpatient-Only (IPO) List and Application of the 2-Midnight Rule,” and then after an instantaneous, critical response from the healthcare community immediately withdrew the article. On January 24, 2019, they reissued the article and again there was rapid negative critique of their scenarios. I, too, see the errors in some of their examples. In my opinion, they could write 100 examples and most would be subject to some criticism. I believe this is why they have been so hesitant to offer examples of the “case-by-case exception” for an inpatient admission when a greater-than-2-midnight stay is not expected. Hopefully CMS learns from this situation just how very hard it is to apply their rules. I maintain that even though their examples and wording are not perfect, there is something for hospitals to learn from this article.
Solid Documentation
The documentation in your medical records serves more than one function. Most importantly, medical documentation serves to communicate information about a patient’s condition and care between healthcare team members to ensure continuity of care, foster quality care, and improve efficiency of care. Medical documentation is also a legal document that serves as evidence of the care provided, especially in the case of a lawsuit. And it is the medical record that ultimately provides the justification and rationale to support payment for the medical items, tests, and services selected and provided to the patient.
Those of us that deal with Medicare are often reminded that documentation must support the medical necessity of services. It is not good when that reminder comes in the form of a claim denial following a complex medical review, such as reviews of the medical necessity of inpatient admissions. It is best to know what is expected up front so we can follow Medicare’s guidelines and make sure our documentation is thorough and solid enough to support Medicare’s requirements for payment.
Likewise, it is helpful when CMS shares the basis for their coverage and payment rationale, preferably in the form of guidance prior to an actual review. Hospitals have been waiting since the 2016 “case-by-case exception” for further guidance on what would justify the use of this exception. Also, hospitals have been confused by statements made in the final rule when total knee arthroplasty was removed from the inpatient-only list in 2018. TKAs are now paid by Medicare when performed as an outpatient or an inpatient, but when is inpatient admission for a TKA appropriate? Finally, CMS has issued a Special Edition MLN Matters Article SE19002 that addresses Total Knee Arthroplasty (TKA) Removal from the Medicare Inpatient-Only (IPO) List and Application of the 2-Midnight Rule. This article describes the circumstances when an inpatient admission for a TKA would be appropriate and even provides specific examples.
An inpatient admission for a TKA is appropriate when 1) there is an expectation of medically necessary hospital services spanning 2 midnights or longer or 2) there is not an expectation of a 2 midnight stay but the physician/practitioner determines other complex medical factors support an inpatient admission.
Providers should read the SE Article carefully as it provides a lengthy discussion on the topic. Here is a summary of some of that discussion. Inpatient admission for a TKA is appropriate when:
- The admitting physician/practitioner has a reasonable expectation that the patient will require medically necessary hospital services spanning 2 midnights or longer and admits the patient to the hospital based on that expectation.
- If the patient remains an inpatient receiving medically necessary hospital services for greater than 2 midnights and the patient’s medical record documents the medical necessity of a hospital level of care, this meets the 2-Midnight Presumption. Under the 2-Midnight Presumption, which helps guide contractor selection of claims for medical review, hospital claims with lengths of stay greater than 2 midnights are presumed to be reasonable and necessary for Medicare Part A payment.
- Even if the patient is discharged prior to a second midnight, as long as documentation supports that at the time the inpatient order was written, there was a reasonable expectation of medically appropriate hospital care spanning 2-Midnights, this supports the 2-Midnight Benchmark. Under the 2-Midnight Benchmark, hospital claims are generally payable when the admitting practitioner reasonably expected the beneficiary to require medically necessary hospital care spanning 2 or more midnights and this expectation is supported by the medical record documentation. The 2-Midnight Benchmark helps guide contractor reviews of short stay hospital claims for Part A payment.
- The admitting physician/practitioner does not expect the patient to need hospital care beyond a second midnight, but determines the patient requires hospital inpatient care based on complex medical factors supported in the medical record and including but not limited to:
- Patient’s history, co-morbidities, and current medical needs
- Severity of signs and/or symptoms, and
- Risk of Adverse Events
The article also emphasizes that TKAs do not always have to be performed as an outpatient and that CMS does not target TKA Short Stay inpatient claims for review.
It is also interesting to note that in the 2018 OPPS Final Rule, CMS made the following statements:
“However, we do not expect a significant volume of TKA cases currently being performed in the hospital inpatient setting to shift to the hospital outpatient setting as a result of removing this procedure from the IPO list. At this time, we expect that a significant number of Medicare beneficiaries will continue to receive treatment as an inpatient for TKA procedures.”
In a seemingly contradictory statement, SE19002 notes, “CMS has not made any pre-determinations on the number of patients receiving TKA procedures that should be treated as an inpatient or outpatient.”
Sometimes even CMS’s documentation is not solid enough to stand up to an audit.
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
January 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Describes changes to and billing instructions for various payment policies implemented in the January 2019 OPPS update.
Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens
Revises travel allowances payment amounts when billed on a per mileage basis using HCPCS code P9603 and when billed on a flat rate basis using HCPCS code P9604 for Calendar Year (CY) 2019.
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.1 Effective April 1, 2019
Calendar Year (CY) 2019 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Provides instructions for the Calendar Year (CY) 2019 Clinical Laboratory Fee Schedule (CLFS), mapping for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment.
OTHER MEDICARE TRANSMITTALS
Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and
Coding Requirements
Updates manual concerning National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits, medically unlikely edits (MUEs), and modifiers -59 and -91 usage.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4188CP.pdf
Local Coverage Determinations (LCDs) – REVISED
Added language to show that MACs have the discretion to host multi-jurisdictional CACs.
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).
Medicare Claims Processing Manual, Chapter 30 Revisions
Chapter revised to provide improved formatting and readability – current policy is not changing.
New Electronic System for Provider Reimbursement Review Board Appeals
MEDICARE SPECIAL EDITION ARTICLES
Total Knee Arthroplasty (TKA) Removal from the Medicare Inpatient-Only (IPO) List and Application of the 2-Midnight Rule - Reissued
Addresses TKA procedures and application of the 2-Midnight Rule now that this procedure has been removed from Medicare’s inpatient-only (IPO) list.
MEDICARE EDUCATIONAL RESOURCES
Appropriate Use Criteria for Advanced Diagnostic Imaging MLN Fact Sheet
ICD-10-CM, ICD10-PCS, CPT, and HCPCS Code Sets MLN Fact Sheet
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Proper Coding for Specimen Validity Testing Billed in Combination with Urine Drug Testing
- Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims
OTHER MEDICARE UPDATES
Medicare Fee-for-Service Recovery Audit Program: Additional Documentation Limits for Medicare Institutional Providers (i.e. Facilities)
RAC ADR limits for facilities updated December 21, 2018
Several years ago, there was a lot of excitement among laboratories and hospitals when CMS stated that a laboratory requisition did not have to be signed by the ordering practitioner. That excitement was short-lived however, when it became apparent that the lack of a signature requirement for lab requisitions did not mean a signed order for the laboratory testing was not required. Upon medical review by a Medicare contractor, the billing entity (such as the hospital) was required to submit a signed practitioner’s order, or other documentation, such as an office progress note, supporting the intent to order the specific laboratory tests. Many laboratories quickly realized it was easier and more efficient to continue to require the physician’s signature on the lab requisition.
Bearing this cautionary tale in mind, what does the proposed policy change to remove the requirement that written inpatient admission orders are a specific requirement for Medicare Part A payment actually mean for hospitals? I certainly do not think it means you no longer need an order for inpatient admission.
In fact, the 2019 Inpatient Prospective Payment System (IPPS) proposed rule states, “This proposal does not change the requirement that an individual is considered an inpatient if formally admitted as an inpatient under an order for inpatient admission.”
What it does mean is a shift in the focus of Medicare reviewers away from the admission order itself. The Proposed Rule affirms that Medicare reviewers will focus on the medical necessity of the inpatient services. The wording in the proposed rule also provides hints as to the types of “technical discrepancies” reviewers may overlook, such as:
- Missing practitioner admission signatures,
- Missing authentication signatures or co-signatures, or
- Signatures occurring after discharge.
Reviewers may also be more willing to allow payment for inpatient admissions when there is not an admission order but “the intent, decision, and recommendation of the ordering physician or other qualified practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record.” This should still be a rare occurrence because hospitals are expected to comply with the Medicare Conditions of Participation which require an admission order.
The rule change for admission orders does not change the “two-midnight” policy. This change, if finalized, will allow hospital personnel to concentrate on ensuring documentation is present in the record to support the medical necessary expectation of a two-midnight stay instead of chasing physicians to obtain signatures before the patient is discharged.
Debbie Rubio
“Inpatient only” services are generally, but now always, surgical services that require inpatient care because of the nature of the procedure, the typical underlying physical condition of patients who require the service, or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged.
- Source: Medicare Claims Processing Manual, Chapter 4 – Part B Hospital
CMS released the Calendar Year (CY) 2018 OPPS/ASC Final Rule last Wednesday November 1st. For CY 2018 CMS proposed two changes to the Inpatient Only (IPO) List and had one request for solicitation. This article provides highlights from section IX. Procedures That Will Be Paid Only as Inpatient Procedures section of the Final Rule.
Total Knee Arthroplasty Public Comments
Many commenters believed that appropriately selected patients who are in excellent health, have no or limited medical comorbidities, and have sufficient caregiver support could be successful candidates for outpatient TKA. Following are TKA topic specific comments and how CMS responded.
Patient Selection for Outpatient TKA
Commenters
- Commenters supported the proposal, with “caveats regarding patient safety, including requests that CMS develop, with input from stakeholders, patient selection criteria and risk stratification protocols for TKA to be performed in an outpatient setting.”
- Two orthopedic specialty societies noted their organizations are in the process of developing these patient selection and protocol tools.
CMS Responds
- CMS believes that surgeons, clinical staff, and medical specialty societies performing outpatient TKA procedures possess the specialized clinical knowledge and experience are most suited to create patient selection guidelines. As such, they do not expect to create or endorse specific guidelines or content.
Determining Appropriate Site for Surgery
Commenters
- There were requests that “CMS explicitly state that the surgeon is the final arbiter of the appropriate site for the surgical procedure, that CMS provide an incentive for outpatient and ambulatory settings performing TKA, PHA, and THA to be a part of a registry such as the American Joint Replacement Registry, and CMS confirm that all surgeons will continue to have the option to select the appropriate setting (inpatient or outpatient) for the procedure.”
CMS Responds
- CMS indicates they “continue to believe that the decision regarding the most appropriate care setting for a given surgical procedure is a complex medical judgment made by the physician based on the beneficiary’s individual clinical needs and preferences and on the general coverage rules requiring any procedure be reasonable and necessary.”
- CMS reminds you that removal from the IPO List does not require the procedure to be performed only on an outpatient basis and that the “2-Midnight” rule continues to be in effect and was established to provide guidance on when an inpatient admission would be appropriate for payment under Medicare Part A (inpatient hospital services).
Impact on Medicare Payment Models
Commenters
- Numerous commenters believe this could potentially impact two current Medicare payment models (Bundled Payment Care Initiative (BPCI) and Comprehensive Care for Joint Replacement (CJR) Model). They expressed concern that younger and healthier patients would be more likely to undergo outpatient TKA’s and that TKA patients in the Inpatient setting would be higher risk and/or likely to need additional post-acute care support. This shift could increase average episode payment affecting a hospital’s ability to fall below an episode established target price.
CMS Responds
- Initially, CMS does not expect a significant volume of TKA cases to shift to the hospital outpatient setting as a result of removing this procedure from the IPO List. They do “intend to monitor the overall volume and complexity of TKA cases performed in the hospital outpatient department to determine whether any future refinements of these models are warranted.”
After consideration of public comments CMS finalized their proposal to remove the TKA procedure described by CPT code 27447 from the IPO List beginning in CY 2018 and to assign the procedure to C-APC 5115 with status indicator “J1”.
Moratorium on Recovery Audit Contractor (RAC) TKA reviews
CMS also finalized the proposal to prohibit RAC “reviews for patient status for TKA procedures performed in the inpatient setting for a period of 2 years to allow time and experience for these procedures under this setting.”
Public Requests for “Removal of” or “Additions to” Procedures on IPO List
Request for “Removal”
CMS notes there were requests to remove several additional procedures from the IPO List. The following table includes CPT codes that were requested to be removed.
Request for “Additions to”
One commenter requested adding CPT 92941 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, and combination of intracoronary stent, arthrectomy and angioplasty, including aspiration thrombectomy when performed, single vessel) to the IPO List because this is an emergent procedure to treat acute myocardial infarction patients.
Codes Finalized for “Removal from” or “Addition to” the IPO List in CY 2018
The following table details the finalized changes to the CY 2018 IPO list.
Should Partial Hip Arthroplasty (PHA) & Total Hip Arthroplasty (THA) be removed from IPO List?
As a reminder, in the CY 2018 OPPS Proposed Rule, CMS requested public comments to several questions related to whether or not PHA (CPT code 27125 (Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty)), and THA, CPT code 27130 (arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft) procedures should be removed from the IPO List.
CMS further sought comment on whether these procedures meet criteria to be added to the ASC Covered Procedures List and how removing these from the IPO List would affect the BPCI and CJR models.
In the Final Rule CMS thanks commenters for their detailed responses and will consider them in future policymaking. So for now, hip procedures remain on the IPO List. Section IX. Procedures That Will Be Paid Only as Inpatient Procedures can be found on pages 657 through 685 of the unpublished Final Rule.
Resources:
Link to unpublished CY 2018 OPPS/ASC Final Rule:
Note: The Final Rule is schedule to be published in the Federal Register on 11/13/2017
Link to CY 2018 OPPS/ASC Final Rule Fact Sheet: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-01.html
Beth Cobb
TRANSMITTALS
Gender Dysphoria and Gender Reassignment Surgery
- MLN Matters® Number: MM9981
- Related Change Request (CR) #: CR 9981
- Related CR Release Date: March 3, 2017
- Effective Date: August 30, 2016
- Related CR Transmittal #: R194NCD
- Implementation Date: April 4, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9981.pdf
- Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.
Summary: Coverage determinations for gender reassignment surgery will continue to be made by the local MACs on a case-by-case basis.
April 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.1
- MLN Matters® Number: MM10002
- Related Change Request (CR) #: CR 10002
- Related CR Release Date: March 10, 2017
- Effective Date: April 1, 2017
- Related CR Transmittal #: R3735CP
- Implementation Date: April 3, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10002.pdf
- Affects providers who submit institutional claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH+H) MACs for services provided to Medicare beneficiaries.
Summary: Instructions and specifications for the Integrated Outpatient Code Editor (I/OCE) used for Outpatient Prospective Payment System (OPPS) and non-OPPS claims.
Clarification of Admission Order and Medical Review Requirements
- MLN Matters® Number: MM9979
- Related Change Request (CR) #: CR 9979
- Related CR Release Date: March 10, 2017
- Effective Date: January 1, 2016
- Related CR Transmittal #: R234BP
- Implementation Date: June 12, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9979.pdf
- Affects physicians submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.
Summary: Clarifies the rulemaking language of the Centers for Medicare & Medicaid Services (CMS) as it relates to “Admission and Medical Review Criteria for Hospital Inpatient Services Under Medicare Part A; Requirements for Physician Orders.”
Billing for Advance Care Planning (ACP) Claims
- MLN Matters® Number: MM10000
- Related Change Request (CR) #: CR 10000
- Related CR Release Date: May 17, 2017
- Effective Date: January 1, 2016
- Related CR Transmittal #: R3739CP
- Implementation Date: June 19, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10000.pdf
- Affects providers who submit claims to Medicare Administrative Contractors (MACs) for Advance Care Planning (ACP) services provided as an optional element of the Annual Wellness Visit (AWV) to Medicare beneficiaries.
Summary: Provides billing instructions for ACP when furnished as an optional element of an AWV. CMS has made the CPT code 99497 (Advance care planning) separately payable for Medicare OPPS claims when the service meets the criteria for separate payment under OPPS.
April 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- MLN Matters® Number: MM 10005
- Related Change Request (CR) #: CR 10005
- Related CR Release Date: March 3, 2017
- Effective Date: April 1, 2017
- Related CR Transmittal #: R3728CP
- Implementation Date: April 3, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10005.pdf
- Affects providers and suppliers who submit claims to Medicare Administrative Contractors (MAC), including Home Health and Hospice (HH&H) MACs, for services provided to Medicare beneficiaries paid under the Outpatient Prospective Payment System (OPPS).
Summary: Describes changes to and billing instructions for various payment policies implemented in the April 2017 OPPS update.
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2017
- MLN Matters Number: MM10036
- Related CR Release Date: March 17, 2017
- Related CR Transmittal Number: R3738CP
- Related Change Request (CR) Number: CR10036
- Effective Date: October 1, 2016
- Implementation Date: July 3, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10036.pdf
- Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Summary: Announces the changes that will be included in the July 2017 quarterly release of the edit module for clinical diagnostic laboratory services. This is a Recurring Update Notification that applies to Chapter 16, Section 120.2, of the ʺMedicare Claims Processing Manual.”
Clarification of Patient Discharge Status Codes and Hospital Transfer Policies
- SE0801 Rescinded March 15, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf
Summary: This article was rescinded on March 15, 2017. Information on the inpatient transfer policy is located in the "Medicare Claims Processing Manual" (100-04), Chapter 3. For questions concerning clarification on the proper usage of patient discharge status codes, providers should be utilizing the "UB-04 Manual" which is maintained by the National Uniform Billing Committee.
OTHER MEDICARE ANNOUNCEMENTS
Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model; Delay of Effective Date
- Interim final rule with comment period; delay of effective date
- https://www.gpo.gov/fdsys/pkg/FR-2017-03-21/pdf/2017-05692.pdf
Summary: This interim final rule with comment period (IFC) further delays the effective date of the final rule entitled ‘‘Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model’’ from March 21, 2017 until May 20, 2017. This IFC also delays the applicability date of the regulations at 42 CFR part 512 from July 1, 2017 to October 1, 2017 and effective date of the specific CJR regulations itemized in the DATES section from July 1, 2017 to October 1, 2017. We seek comment on the appropriateness of this delay, as well as a further applicability date delay until January 1, 2018.
Proposed Decision Memo for Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) (CAG-00449N)
Summary: CMS) proposes that the evidence is sufficient to cover supervised exercise therapy (SET) for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic peripheral artery disease (PAD).
Hospitals are at T-7 days for the March 8, 2017 compliance date with the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act). In the spirit of last minute preparations, this article is meant to reinforce key definitions, provide CMS responses to comments found in the 2017 IPPS Final Rule in the form of questions and answers and links to MOON resources.
Definitions
The MOON is intended to inform beneficiaries who receive observation services for more than 24 hours that they are outpatients receiving observation services and not inpatients, and the reasons for such status.
- Outpatient Defined
The Medicare Claims Processing Manual (Pub. 100-04), Chapter 1, Section 50.3.1, defines an Outpatient as “a person who has not been admitted as an inpatient but who is registered on the hospital or critical access hospital (CAH) records as an outpatient and receives services (rather than supplies alone) directly from the hospital or CAH.”
- Observation Services
Observation services are “services that are reasonable and necessary, specifically ordered by a physician or other nonphysician practitioner authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient services, and meet other published Medicare criteria for payment.”
“Individuals receiving observation services will always be registered as outpatients; however, not all outpatients receive observation services.”
- Decision to order Observation Services
“By definition… the reason for ordering observation services will always be the result of a physician’s decision that the individual does not currently require inpatient services and observation services are needed for the physician to make a decision regarding whether the individual needs further treatment as a hospital inpatient or if the individual is able to be discharged from the hospital.” (Source: 2017 IPPS Final Rule referencing the Medicare Benefits Policy Manual (Pub. 100-02), Chapter 6, Section 20.6.)
Questions and Answers
Again, CMS’ responses to comments from the 2017 IPPS Final Rule have been formatted as Questions and Answers.
Question: Several commenters requested clarification as to whether the timeframe starts:
- After services begin following the written order for observation services;
- When related services commence if such services commence before the written order was executed and the patient occupies an outpatient bed count; or
- Based on the documentation of when nursing care began.
Answer: CMS indicated “there may be times when an individual is subject to an order for observation services, but is not actually receiving observation services. For example, following an order for observation services in an emergency department, a hospital may need to wait to begin furnishing observation services until a bed is available for the patient. In this situation, services are considered initiated when observation services commence.”
They went on to clarify “that the start of observation services, for the purposes of determining when more than 24 hours of observation services have been received, is the clock time as documented in the patient’s medical record at which observation services are initiated (furnished to the patient) in accordance with a physician’s order.”
Question: Will time be counted as Billable or Elapsed Time?
Answer: CMS believes using elapsed time is most consistent with language in the NOTICE Act. “Therefore, for purposes of identifying the 24-hour timeframe for which an individual has received observation services, and thus is required by the NOTICE Act to receive notice by the hospital or CAH, observation time will be measured as the elapsed time in hours beginning at the clock time documented in the patient’s medical record, which coincides with the time that observation care is initiated in accordance with a physician’s order.”
Question: What if the Inpatient Admission occurs prior to delivery of the MOON?
Answer: As recommended by a commenter, CMS agrees that when “an inpatient admission occurs prior to delivery of the MOON, the MOON should be annotated with date and time of the inpatient admission. Therefore, we are requiring that, in the event that a patient is subsequently admitted as a hospital inpatient directly after receiving observation services for more than 24 hours, and the inpatient admission occurs prior to delivery of the MOON, the MOON be annotated with the date and time of the inpatient admission. Additional guidance regarding elements for the free text field of the MOON will be provided in the CMS Internet Only Manual.”
Question: How will the MOON work with the 2-Midnight Policy?
Answer: “The NOTICE Act requires hospitals to inform patients who have remained outpatients of the hospital and received observation services for more than 24 hours that they are not hospital inpatients and are subject to potentially different cost-sharing requirements and postacute care benefits than someone who has been admitted as an inpatient. We note that a scenario could arise whereby a patient is admitted to the hospital immediately after being a hospital outpatient receiving observation services for greater than 24 hours. In such a scenario, the inpatient admission may be payable under Medicare Part A under the 2-midnight policy and, as stated earlier, the hospital or CAH would still be required to furnish the MOON to the patient within 36 hours after the time the individual begins receiving observation services.”
Question: Can a Hospital or CAH deliver the MOON before an individual has received more than 24 hours of observation services as an inpatient?
Answer: Yes.
- This affords hospitals flexibility to deliver the MOON consistent with any applicable state law requiring notice within 24hrs.
Note: “Hospitals and CAHs subject to State law notice requirements may also attach an additional page to the MOON to supplement the “Additional Information” section in order to communicate additional content required under State law, or may attach the notice required under State law to the MOON.”
- This allows hospitals and CAHs to spread out the delivery of the MOON and other hospital paperwork in an effort to avoid overwhelming and confusing beneficiaries.
Note: CMS does not encourage delivery of the MOON at the initiation of outpatient observation services.
Question: Can the MOON form be altered?
Answer: No, because the MOON is a standard form approved by the Office of Management and Budget (OMB), Hospitals and CAHs are not permitted to alter the included language, only the information to be included in the free text fields.
The MOON must remain two pages, except as needed for the additional information field. The pages of the notice can be two sides of one page or one side of separate pages, but must not be condensed to one page.
Hospitals may include their business log and contact information on the top of the MOON. Text may not be shifted from page 1 to page 2 to accommodate large logos, address headers, or any other information.
Question: Can you use “drop down” boxes in the free text field for telling the patient why they are not an inpatient?
Answer: CMS indicates in the 2017 IPPS Final Rule, “We may consider, in the future, the other suggestions commenters made to improve the MOON, such as checkboxes with common reasons for the patient’s outpatient status or suggested narratives for insertion in this section.”
Question: If more space is needed for “Additional Information”, may a Hospital attach additional pages to the MOON?
Answer: Yes
Question: Can you (CMS) clarify the effect of a resident’s order for services on the counting of hours of observation care?
Answer: “To the extent that a resident is authorized by State licensure law and hospital staff bylaws to order outpatient services, once observation services are initiated in accordance with the resident’s order, the 24 hour time period will commence.”
Question: What do you do if the individual receiving the notice is unable to read its written contents and/or comprehend the required oral explanation?
Answer: As discussed in the proposed rule (81 FR 25134), an English language version of the proposed MOON was submitted to OMB for approval. We stated in the proposed rule that once we receive OMB approval, a Spanish language version of the MOON will be made available. If the individual receiving the notice is unable to read its written contents and/or comprehend the required oral explanation, we expect hospitals and CAHs to employ their usual procedures to ensure notice comprehension. (We refer readers, for example, to the Medicare Claims Processing Manual (Pub. 100–4), Chapter 30, Section 40.3.4.3., for similar existing procedures related to notice comprehension for the Advance Beneficiary Notice of Noncoverage (ABN).) Usual procedures may include, but are not limited to, the use of translators, interpreters, and assistive technologies. Hospitals and CAHs are reminded that recipients of Federal financial assistance have an independent obligation to provide language assistance services to individuals with limited English proficiency (LEP) consistent with section 1557 of the Affordable Care Act and Title VI of the Civil Rights Act of 1964. In addition, recipients of Federal financial assistance have an independent obligation to provide auxiliary aids and services to individuals with disabilities free of charge, consistent with section 1557 of the Affordable Care Act and section 504 of the Rehabilitation Act of 1973.”
Question: Does the beneficiary have appeal rights under the NOTICE Act?
Answer: No, “The MOON is a required informational/educational notice regarding patient status provided by a hospital or CAH when the beneficiary is still in the hospital or CAH and receives observation services as an outpatient for more than 24 hours. The MOON explains the current status of the patient as an outpatient and not an inpatient, in addition to the implications of being an outpatient receiving observation services. As we explained in the proposed rule, delivery of the MOON does not constitute an initial determination issued in response to a claim for benefits, and the MOON itself is not a notice of an initial determination (81 FR 25134). Furthermore, delivery of the MOON by a hospital or CAH does not constitute a denial of coverage of any services, and does not constitute a noncoverage decision with respect to post-hospital SNF care as asserted by the commenter. In fact, generally beneficiaries will still be receiving care when the MOON is delivered and will sometimes be formally admitted as inpatients after delivery of the MOON.
The NOTICE Act does not provide for appeal rights regarding the notice itself, which makes sense given the nature of the document, as explained above. The NOTICE Act also does not afford any new appeal rights beyond those already available (under section 1869 of the Social Security Act), nor does the NOTICE Act limit or restrict currently available appeal rights. Consistent with the legislation, the proposed rule did not propose to expand or limit appeal rights. For the reasons discussed above, we are not adopting the various recommendations with respect to amending the MOON to include appeal rights or an explanation of the lack of appeal rights.”
MOON and Condition Code 44
“In rare circumstances where a physician initially orders inpatient services, but following internal utilization review (UR) performed while the patient is hospitalized, the hospital determines that the services do not meet its inpatient criteria and the physician concurs with UR and orders the discontinuation of inpatient services and initiation of outpatient observation services (that is, a Condition Code 44 situation), we stated in the proposed rule that the MOON would be delivered as required by the NOTICE Act (when outpatient observation services have been ordered and furnished for more than 24 hours). If observation services are ordered when Condition Code 44 applies, the 24-hour time period for observation notification commences at the same time that observation services are initiated under a physician’s order, consistent with existing policy for observation services furnished to outpatients. (We refer readers to the Medicare Claims Processing Manual (Pub. 100–04), Chapter 1, Section 50.3.)
As discussed in the proposed rule and as stated in the notice announcing CMS Ruling CMS–1455–R (78 FR 16614), the Part B Inpatient Billing Ruling, in cases where reviewers find that an inpatient admission was not medically reasonable and necessary after the beneficiary is discharged, and thus, not appropriate for payment under Medicare Part A, the beneficiary’s patient status remains ‘‘inpatient’’ as of the time of the inpatient admission. The patient’s status is not changed to outpatient because the beneficiary was formally admitted as an inpatient, and there is no provision to change a beneficiary’s status after he or she is discharged from the hospital. Where CMS denies a claim after the beneficiary has been discharged because the inpatient admission was not medically reasonable and necessary, there would be no need to issue the MOON because the individual’s status remains inpatient, despite the fact that the inpatient admission was improper. Similarly, where a hospital determines through UR after a beneficiary is discharged that his or her inpatient admission was not reasonable and necessary and the hospital bills the services that were provided on a Medicare Part B claim, the NOTICE Act notification requirements would not apply for these individuals because their status would also remain inpatient.” (Excerpt from page 281-282 2017 IPPS Final Rule pdf document)
MOON Resources
- CMS 2017 IPPS Final Rule web page: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2017-IPPS-Final-Rule-Home-Page.html
- See section III. L. Hospital and CAH Notification Procedures for Outpatients Receiving Observation Services (pages 277 – 292 Final Rule pdf document)
- CMS Transmittal 3695, Date: January 20, 2017
Subject: medicate Outpatient Observation Notice (MOON) Instructions: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/CR9935-MOON-Instructions.pdf
- CMS MLN Matters® Number: MM9935: Medicare Outpatient Observation Notice (MOON) Instructions: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9935.pdf
- CMS Beneficiary Notices Initiative web page: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html?redirect=/BNI/
- CMS Product No. 11435: Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask! at: https://www.medicare.gov/Pubs/pdf/11435.pdf
Beth Cobb
TRANSMITTALS
Calendar Year (CY) 2017 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
- MLN Matters® Number: MM9909
- Related Change Request (CR) #: CR 9909
- Related CR Release Date: December 29, 2016
- Effective Date: January 1, 2017
- Related CR Transmittal #: R3687CP
- Implementation Date: January 3, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9909.pdf
- Affects clinical diagnostic laboratories submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Summary: Provides instructions for the Calendar Year (CY) 2017 clinical laboratory fee schedule, mapping for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment. This update applies to Chapter 16, Section 20 of the “Medicare Claims Processing Manual.”
April 2017 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
- MLN Matters® Number: MM9945
- Related Change Request (CR) #: CR 9945
- Related CR Release Date: January 13, 2017
- Effective Date: April 1, 2017
- Related CR Transmittal #: R3692CP
- Implementation Date: April 3, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9945.pdf
- Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Summary: Provides the April 2017 quarterly update Average Sales Price (ASP) drug pricing files for Medicare Part B drugs.
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2017
- MLN Matters® Number: MM9934
- Related Change Request (CR) #: CR 9934
- Related CR Release Date: January 13, 2017
- Effective Date: October 1, 2016
- Related CR Transmittal #: R3691CP
- Implementation Date: April 3, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9934.pdf
- Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Summary: Changes that will be included in the April 2017 quarterly release of the edit module for clinical diagnostic laboratory services.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 2nd Qtr Notification for FY 2017
- Related Change Request (CR) #: CR 9978
- Related CR Release Date: January 11, 2017
- Effective Date: January 19, 2017
- Related CR Transmittal #: R280FM
- Implementation Date: January 19, 2017
- https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R280FM.pdf
- Affects Medicare providers
Summary: Medicare Regulation 42 CFR Section 405.378 provides for the charging and payment of interest on overpayments and underpayments to Medicare providers. The Secretary of Treasury certifies an interest rate quarterly. The Medicare contractors shall implement an interest rate of 9.50 percent effective January 19, 2017 for Medicare overpayments and underpayments.
Medicare Outpatient Observation Notice (MOON) Instructions
- MLN Matters® Number: MM9935
- Related Change Request (CR) #: CR 9935
- Related CR Release Date: January 20, 2017
- Effective Date: February 21, 2017
- Related CR Transmittal #: R3695CP
- Implementation Date: February 21, 2017
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9935.pdf
- Affects hospitals, including Critical Access Hospitals (CAHs) submitting claims to Medicare Administrative Contractors (MACs) for outpatient observation services provided to Medicare beneficiaries.
Summary: Updates Chapter 30 of the “Medicare Claims Processing Manual” to include the Medicare Outpatient Observation Notice (MOON), CMS-10611, and related instructions. Providers should use the MOON to inform Medicare beneficiaries when they are an outpatient receiving observation services, and are not an inpatient of the hospital or a Critical Access Hospital (CAH). The instructions included in Chapter 30 provide guidance for proper issuance of the MOON.
OTHER MEDICARE ANNOUNCEMENTS
January 2017 Medicare Quarterly Provider Compliance Newsletter
- Guidance to address billing errors
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909313.pdf
Summary: Provides education on how to avoid common billing errors and other erroneous activities when dealing with the Medicare Fee-For-Service (FFS) Program. It includes guidance to help health care professionals address and avoid the top issues of the particular quarter. Hospital topics this quarter include facet joint injections, radiation therapy, stem cell transplants, and long-term acute care (LTAC) stays.
Final Rule: Revisions to the Office of Inspector General’s Exclusion Authorities
- Federal Register, January 12, 2017
- Effective: February 13, 2017
- https://www.gpo.gov/fdsys/pkg/FR-2017-01-12/pdf/2016-31390.pdf
Summary: This final rule amends the regulations relating to exclusion authorities under the authority of the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS or the Department). The final rule incorporates statutory changes, early reinstatement provisions, and policy changes, and clarifies existing regulatory provisions.
Final Rule: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR)
- Federal Register, January 3, 2017
- Effective: February 18, 2017
- https://www.federalregister.gov/documents/2017/01/03/2016-30746/medicare-program-advancing-care-coordination-through-episode-payment-models-epms-cardiac
Summary: This final rule implements three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation (CR) Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement model under section 1115A of the Social Security Act. Acute care hospitals in certain selected geographic areas will participate in retrospective episode payment models targeting care for Medicare fee-for-service beneficiaries receiving services during acute myocardial infarction, coronary artery bypass graft, and surgical hip/femur fracture treatment episodes. All related care within 90 days of hospital discharge will be included in the episode of care. We believe these models will further our goals of improving the efficiency and quality of care for Medicare beneficiaries receiving care for these common clinical conditions and procedures.
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