Knowledge Base Category -
“We rarely talk about cost. We talk about waste, quality, and safety, and we find our costs go down.”
- Patrick Hagan, former COO of Seattle Children’s Hospital
Risk Factor: Socio-economic Status
The Establishing Beneficiary Equity in the Hospital Readmission Reduction Program Act of 2015 (S. 688 and H.R. 1343) would have required the CMS to account for socio-economic status when calculating risk-adjusted readmission penalties. This bill garnered support from the Association of American Medical Colleges as well as the American Hospital Association. You can read more about this Act in a related MMP article.
A year later the House Ways and Means Committee released the Helping Hospitals Improve Patient Care Act of 2016 (H.R. 5273) that included a modified version of H.R. 1343. This latest version of the bill was passed in the House and was sent to the Senate where it was read twice and referred to the Committee on Finance.
Fast Forward to the 2019 IPPS Proposed Rule which includes a discussion about “Accounting for Social Risk Factors” (including socioeconomic status) in the following Programs discussed in the Proposed Rule:
- Hospital Readmission Reduction Program (HRRP),
- Hospital Value Based Purchasing (VBP) Program,
- Hospital Acquired Condition (HAC) Reduction Program,
- Hospital Inpatient Quality Reporting (IQR) Program,
- IPPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program, and
- Long Term Care Hospital Quality Reporting Program (LTCH QRP).
Accounting for Social Risk Factors
CMS notes their “commitment to ensuring that medically complex patients, as well as those with social risk factors, receive excellent care. We discussed how studies show that social risk factors, such as being near or below the poverty level as determined by HHS, belonging to a racial or ethnic minority group, or living with a disability, can be associated with poor health outcomes and how some of this disparity is related to the quality of health care.”
Specific CMS aims within their core objectives include:
- Improving health outcomes,
- Attaining health equity for all beneficiaries, and
- Ensuring that complex patients as well as those with social risk factors receive excellent care.
The Office of the Assistant Secretary for Planning and Evaluation (ASPE) and the National Academy of Medicine
The ASPE and National Academy of Medicine have examined the influence of social risk factors in the CMS value-based purchasing programs. To date, as required by the IMPACT Act of 2014, ASPE has provided a report to Congress where they found that “in the context of value-based purchasing programs, dual eligibility was the most powerful predictor of poor health care outcomes among those social risk factors they examined and tested.” ASPE is continuing to examine this issue in a second report required by the IMPACT Act that is due to Congress in the fall of 2019.
National Quality Forum (NQF)
CMS noted in the FY 2018 IPPS/LTCH PPS Final Rule, that the NQF “undertook a 2-year trial period in which certain new measures and measures undergoing maintenance review have been assessed to determine if risk adjustment for social risk factors is appropriate for those measures.” This period ended April 2017.
NQF Trial Conclusion:
The NQF notes in the July 2017 Social Risk Trial Final Report Abstract that “the trial period has illuminated the feasibility of adjusting measures for social risk, with 17 measures endorsed by NQF for factors such as a person’s level of education.” The NQF has extended the socioeconomic status (SES) Trial, allowing further examination of social risk factors in outcome measures.
The Centers for Medicare and Medicaid Services
CMS solicited feedback in the FY and CY 2018 Proposed Rules on which social risk factors provide the most valuable information to stakeholders for illuminating differences in outcome rates among patient groups. Commenters encouraged CMS to stratify measures by other social risk factors such as age, income, and educational attainment (82 FR 38404).
CMS Next Steps
As next steps, CMS is considering the following:
- Options to reduce health disparities among patient groups within and across hospitals by increasing the transparency of disparities as shown by quality measures,
- Implementing a hospital-specific disparity method that would promote quality improvement by calculating difference in outcome rates among patient groups within a hospital while accounting for their clinical risk factors,
- Implementing a method to assess hospitals’ outcome rates for subgroups of patients, such as dual eligible patients, across hospitals, allowing for a comparison among hospitals on their performance caring for patients with social risk factors.
Specific to the Hospital IQR Program, CMS acknowledges the complexity of interpreting stratified outcome measures and plans to stratify Pneumonia Readmission measure (NQF #0506) data by highlighting both hospital-specific disparities and readmission rates specific for dual-eligible beneficiaries across hospitals for dual-eligible patients in hospitals’ confidential feedback reports beginning Fall 2018. CMS is considering expanding confidential hospital feedback reports for other measures and eventually making this data publicly available on the Hospital Compare website.
CMS believes “the stratified results will provide hospitals with information that could illuminate disparities in care or outcome, which could subsequently be targeted through quality improvement efforts. We further believe that public display of this information could drive consumer choice and spark additional improvement efforts.” CMS plans to continue to work with the ASPE, the public and key stakeholders to “identify policy solutions that achieve the goals of attaining health equity for all beneficiaries and minimizing unintended consequences.”
Beth Cobb
“Observation care services are covered only when provided by the order of a physician or another individual authorized by state licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient tests. These services must be deemed reasonable and necessary to be covered by Medicare. Please share with appropriate staff.”
- Source: Palmetto GBA JJ April 10, 2018 Daily Newsletter
Palmetto GBA, the Jurisdiction J (JJ) Medicare Administrative Contractor (MAC) included the above statement in their April 10, 2018 Daily Newsletter. The reminder also included a link to an article about Observation Care on the Palmetto GBA website.
Given that Palmetto GBA started the conversation, MMP would also like to make appropriate staff aware of the fact that there is a new JJ Outpatient Observation Bed/Room Services (L34552) Local Coverage Determination (LCD). This article will walk you through LCD L34552.
LCD Coverage Indications, Limitations and/or Medical Necessity
Observation Services: What it is?
- “Observation services are defined as the use of a bed and periodic monitoring by a hospital's nursing or other ancillary staff, which are reasonable and necessary to evaluate an outpatient's condition to determine the need for possible inpatient admission.”
- “The services may be considered covered only when provided under a physician's order (or under the order of another person who is authorized by state statute and the hospital's bylaws to admit patients or order outpatient testing).”
- “Outpatient observation services must be patient specific and not part of the facilities standard operating procedure or protocol for a given diagnosis or service. Observation services, generally, do not exceed 24 hours.”
Observation Services: What it is not?
- “Outpatient observation services are not to be used as a substitute for medically necessary inpatient admissions. Outpatient observation services are not to be used for the convenience of the hospital, its physicians, patients, or patient's families, or while awaiting placement to another health care facility.”
Documentation Palmetto expects to find in the Medical Record
LCD L34552 includes the following five elements that need to be included in the medical record when a patient is receiving Observation Services:
- “The attending physician's order including “clock time” for the observation service or “clock time” can be noted in the nursing admission notes/observation unit notes outlining the patient’s condition and treatment.
- Observation time which begins at the clock time documented in the patient’s medical record, and which coincides with the time the patient is placed in a bed for the purpose of initiating observation care in accordance with a physician’s order.
- The ending time for observation occurs either when the patient is discharged from the hospital or is admitted as an inpatient. The time when a patient is “discharged” from observation status is the clock time when all clinical or medical interventions have been completed, including any necessary follow-up care furnished by hospital staff and physicians that may take place after a physician has ordered that the patient be released or admitted as an inpatient. However, observation care does not include time spent by the patient in the hospital subsequent to the conclusion of therapeutic, clinical, or medical interventions, such as time spent waiting for transportation to go home.
- The beneficiary is under the care of a physician during the period of observation as documented in the medical record by admission, discharge, and appropriate progress notes.
- Risk stratification criteria (such as intensity of service and severity of illness) were used in considering potential benefits of observation care.”
Observation Services Triggering Medical Review
Tucked between the Coverage Indications, Limitations and/or Medical Necessity and the Categories of Observation Services is to me one of the most important sentences in this LCD:
“Observation claims exceeding 48 hours may be subject to medical review.”
So why 48 hours, in the related Observation Care article mentioned previously? Palmetto notes that CMS has indicated that “In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours. In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours.”
Additionally, with the implementation of the 2-Midnight Rule effective October 1, 2013, outpatient observation services spanning greater than 48 hours should be closely followed to convert to Inpatient when appropriate or work with the Physician to determine why he/she believes the patient is continuing to require observation care.
Outpatient Observation Services Categorized
The LCD indicates that outpatient observation services fall into one of three categories.
- Diagnostic Testing
Under this category, for scheduled invasive outpatient diagnostic tests, routine preparation and immediate recovery after the test is not considered to be an observation service. If further monitoring is required as a result of a significant adverse reaction from the test then outpatient observation services may be reasonable and necessary.
“Observation services begin at that point in time when the reaction occurred and would end when it is determined whether or not the patient required inpatient admission. Medical review decisions will be based on the documentation in the patient’s medical record.”
- Outpatient Therapeutic Services
“Observation status does not apply when a beneficiary is treated as an outpatient for the administration of blood only and receives no other medical treatment. The use of the hospital facilities is inherent in the administration of the blood and is included in the payment for administration.
When the patient has been scheduled for ongoing therapeutic services as a result of a known medical condition, a period of time is often required to evaluate the response to that service. This period of evaluation is an appropriate component of the therapeutic service and is not considered an observation service.
The observation service begins at that point in time when a significant adverse reaction occurred that is above and beyond the usual and expected response to the service.”
- Patient Evaluation
“When a patient arrives at the facility with an unstable medical condition (generally via the Emergency Department), observation services may be reasonable and necessary to evaluate the medical condition to determine the need for a possible admission to the hospital as an inpatient.
An unstable medical condition can be defined as:
· variance from generally accepted normal laboratory values; and
· clinical signs and symptoms present that are above or below those of normal range (for the patient) and are such that further monitoring and evaluation is needed. Changes in the patient's status or condition are anticipated and immediate medical intervention may be required.
Documentation in the patient's medical record must support the medical necessity of the observation service.
Inpatient Status Changed to Observation Status is a No Go without Condition Code 44
While this LCD does not mention Condition Code 44, it does include the following statement:
“Upon internal review performed before the claim was initially submitted and upon the hospital determining that the services did not meet its inpatient criteria, an inpatient status may not be automatically changed to observation status. An observation stay must adhere to the criteria as described in the “Coverage Indications, Limitations and/or Medical Necessity” section of this LCD.”
Documentation Requirements
When reading an LCD I often jump to the end where you find the “Documentation Requirements” detailing what the MAC expects to find when reviewing a record for medical necessity of the services provided. Specific to this LCD, “documentation must be legible, relevant and sufficient to justify the services billed. The documentation for Outpatient Observation must include:
- The attending physician's order including “clock time” for the observation service or “clock time” can be noted in the nursing admission notes/observation unit notes outlining the patient’s condition and treatment.
- The physician's admission/progress note which clearly indicates the patient's condition, signs and symptoms that necessitate the observation stay.
- Supporting ancillary reports such as laboratory and diagnostic test reports.
Legible documentation in the medical record must clearly support the medical necessity and reasonableness of the observation services. The documentation should clearly state the method of assessment during observation and, if necessary, treatment in order to determine if the patient should be admitted or may be safely discharged.”
Key Takeaways for Providers
The three major points Providers need to be mindful of when internally reviewing outpatient claims where the beneficiary was receiving observation services are:
- To support medical necessity of an outpatient stay receiving observation services, the medical record should include the following elements:
- A timed order for observation services,
- Physician documentation indicating a patient’s condition, signs and symptoms necessitating observation services.
- All ancillary reports supporting the patient evaluation (i.e. labs and diagnostic test results).
- An inpatient status may not automatically be changed to an “observation stay.” If the patient was still in house at the time this determination was made you would need to follow Condition Code 44 guidance. You can access further guidance specific to Condition Code 44 in MLN Matters Article SE0622.
- “Observation claims exceeding 48 hours may be subject to medical review.” Make patients receiving observation services a priority for your Utilization Review staff.
Beth Cobb
The March 1, 2018 edition of the Medicare Learning Network e-newsletter mlnconnects, includes a list of new and revised Provider Compliance Tips Fact Sheets. This article focuses on the new Provider Compliance Tips for Bariatric Surgery Fact Sheet.
Provider Compliance Tips for Bariatric Surgery Fact Sheet
CMS notes there is a National Coverage Determination (NCD) 100.1 for Bariatric Surgery for Treatment of Obesity. As a matter of fact this NCD is now in its 5th iteration with the first version having an effective date of 10/1/1979.
Bariatric procedures are performed to treat the comorbid conditions associated with morbid obesity and a beneficiary must meet all of the following Medicare coverage criteria:
- Have a Body-Mass Index (BMI) of ≥ 35 kg/m2,
- At least one comorbidity related to obesity, and
- Had prior unsuccessful medical treatment for obesity.
Bariatric surgery as treatment for obesity alone remains non-covered by Medicare.
Reasons for denials cited in the fact sheet include insufficient documentation, documentation fails to support procedures as reasonable and necessary, and Providers do not comply with signature requirements.
Bariatric Surgery Medical Necessity Reviews
Bariatric Surgery is not new, so the question for me is why a Fact Sheet now? More importantly, for hospitals performing bariatric procedures, have you self-audited medical record documentation to validate that procedures being performed are reasonable and necessary? If not, you should because what I have found in writing this article is that Medicare Auditors have and continue to review these procedures for medical necessity.
Comprehensive Error Rate Testing (CERT)
The Fact Sheet includes the July 2014 edition of the Medicare Quarterly Compliance Newsletter as a resource for more information about bariatric surgery. The newsletter includes an overview of a special study of HCPCS codes for bariatric surgery (43644 and 43770) conducted by the CERT. They found that insufficient documentation (something was missing from the record) caused approximately 98 percent of the improper payments. The newsletter also provides examples of improper payments for bariatric surgery.
Supplemental Medical Review Contractor (SMRC): Completed Project 2015-0216 Bariatric Surgery
The SMRC completed a review of bariatric surgery for the treatment of morbid obesity at the direction of CMS as a result of the 2014 CERT special study. The Project included a review of claims with dates of service from January 1, 2014 through December 31, 2014.
In their report they noted that CMS identified Type 2 diabetes mellitus as being one co-morbidity related to obesity and go on to indicate that CMS delegated the authority to determine additional co-morbidities and whether coverage will be extended to other types of bariatric surgery than outlined in NCD 100.1 to the Medicare Administrative Contractors (MACs).
At the time this project was completed, co-morbidities covered by one or more MAC included:
- Refractory hypertension (HTN),
- Obesity-induced cardiomyopathy,
- Clinically significant obstructive sleep apnea,
- Obesity-related hypoventilation,
- Pseudo tumor cerebri (documented idiopathic intracerebral HTN),
- Severe arthropathy of spine or weight-bearing joints, and
- Hepatic steatosis without prior evidence of active inflammation.
The Project overall error rate was 35 percent. This included claims recommended for denial due to providers not submitting the requested records and claims recommended for denial after review. Specific examples of insufficient documentation provided in the report included:
- Lack of documentation to support that the beneficiary had been previously unsuccessful with medical attempts (supervised dieting, exercise) at weight loss prior to surgical intervention,
- The submitted documentation did not include a signed operative report, and
- The submitted documentation did not include preoperative psychological evaluation with clearance for surgery and if treatable metabolic causes for obesity, such as adrenal or thyroid disorders, had been ruled out.
Recovery Auditors approved issue: Bariatric Surgery
Complex reviews for medical necessity of bariatric surgery is a current review issue for all four Recovery Audit Regions in the country. The approval date for this issue varies among the four Regions from November 2016 to February 1, 2017. Remember that the Recovery Audit look back period is three years.
Office of Inspector General (OIG) Work Plan: Review of Medicare Payments for Bariatric Surgeries
In October 2017, the OIG added the Review of Medicare Payments for Bariatric Surgeries to their Active Work Plan Issues. As with the SMRC, the OIG referenced the CERT special study in the announcement. The OIG indicated that they will be reviewing “supporting documentation to determine whether the bariatric services performed met the conditions for coverage and were supported in accordance with Federal requirements.”
Next Step: Know the Coverage Requirements
While the new Fact Sheet references NCD 100.1 it does not reference additional guidance by the MACs. Do you know if your MAC has published additional guidance? The following table details the MACs that have published a Local Coverage Determination (LCD) or Coverage Article.
As you can see, it is pretty clear why a Fact Sheet now and MMP, Inc. encourages you to become familiar with the NCD, any applicable MAC guidance, use the new Fact Sheet and Medicare Quarterly Compliance Newsletter as teaching tools and make sure your records support the medical necessity for the procedure.
Beth Cobb
MEDICARE TRANSMITTALS
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - April 2018 Update
The April 2018 updates of specific biosimilar biological product HCPCS code, modifiers used with these biosimilar biologic products and an autologous cellular immunotherapy treatment.
E/M Service Documentation Provided By Students (Manual Update)
Allows the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work.
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 24.1, Effective April 1, 2018
Medicare Fee-for-Service Recovery Audit Program Additional Documentation Limits for Medicare Institutional Providers (i.e. Facilities)
New ADR limits for the Recovery Audit Program.
Diagnosis Code Update for Add-on Payments for Blood Clotting Factor Administered to Hemophilia Inpatients
Updates to diagnosis codes required in order to allow add-on payments under the Inpatient Prospective Payment System (IPPS) for blood clotting factor administered to hemophilia inpatients.
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Changes in the April 2018 quarterly update to the Clinical Laboratory Fee Schedule (CLFS).
Replacement of Mammography HCPCS Codes, Waiver of Coinsurance and Deductible for Preventive and Other Services, and Addition of Anesthesia and Prolonged Preventive Services – REVISED
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits – REVISED
Revised to add HCPCS code G0475 as a code that is subject to CLIA edits effective, April 13, 2015.
Modifications to the Implementation of the Paperwork (PWK) Segment of the Electronic Submission of Medical Documentation (esMD) System
Enables MACs to receive unsolicited documentation (also known as paperwork (PWK)) via the Electronic Submission of Medical Documentation (esMD) system.
Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2018 Update
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.
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
A maintenance update of the International Classification of Diseases, Tenth Revision (ICD-10) conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
MEDICARE COVERAGE UPDATES
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)
Effective May 25, 2017, new NCD to cover Supervised Exercise Therapy (SET) for beneficiaries with Intermittent Claudication (IC) for the treatment of symptomatic Peripheral Artery Disease (PAD).
Decision Memo for Implantable Cardioverter Defibrillators (CAG-00157R4)
Changes to the ICD NCD from the 2005 reconsideration.
OTHER MEDICARE UPDATES
Medicare Fee-for-Service Recovery Audit Program Additional Documentation Limits for Medicare Institutional Providers (i.e. Facilities)
Correction: Hospital Outpatient Prospective Payment (OPPS) and Ambulatory Surgical Center (ASC) Payment Systems and Quality Reporting Programs
https://www.gpo.gov/fdsys/pkg/FR-2018-01-31/pdf/C1-2017-27949.pdf
Targeted Probe and Educate (TPE) Website Update
New resources available on the TPE website.
MEDICARE EDUCATIONAL RESOURCES
Transition to New Medicare Numbers and Cards FACTSHEET
“Typically, repainting needs to occur every few years and before you repaint, you need to strip out the layers of paint from underneath. Otherwise it looks messy! Unfortunately, CMS has been applying new layers of paint without applying this essential step.”
- Seema Verma, the Administrator of the Centers for Medicare and Medicaid Services speaking at the Health Care Payment Learning and Action Network Fall Summit, October 30, 2017
The American Hospital Association (AHA) published the report Assessing the Regulatory Burden on Health Systems, Hospitals and Post-Acute Care Providers to determine the impact of regulatory burden” on hospitals, health systems and post-acute care (PAC) facilities. The purpose of the report is twofold. First, inform policymakers, lawmakers and the public about the administrative impact federal regulatory requirements have on the ability to furnish high-quality patient care. Secondarily, this report seeks to offer a starting point for discussions on implementing meaningful regulatory reform.
The AHA approached this endeavor with a thorough review of the Federal Register and the U.S. Code of Federal Regulations for regulations impacting hospitals and PACs across the following nine domains:
- Quality Reporting,
- New Models of Care/Value-Based Payment (VBP) Models,
- Meaningful Use (MU) of Electronic Health Records (EHRs),
- Hospital Conditions of Participation (CoPs),
- Program Integrity,
- Fraud and Abuse,
- Privacy and Security,
- Post-Acute Care, and
- Billing and Coverage Verification Requirements.
The four agencies described by the AHA as being “the primary drivers of federal regulations impacting these providers” are the Centers for Medicare and Medicaid Services (CMS), the Office of Inspector General (OIG), the Office of Civil Rights (OCR) and the Office of the National Coordinator for Health Information Technology (ONC).
Report Findings by the Numbers
- 629 – The number of mandatory regulatory requirements in effect as of March 2017.
- 341 – The number of hospital related requirements.
- 288 – The number of PAC related requirements.
- $38.6 Billion – The national cost of administrative activities related to regulatory compliance across the 9 domains.
- 59 – The number of FTEs an average-sized hospital (161 beds) dedicates to regulatory compliance. PAC regulations require an additional 8.1 FTEs.
- 4.6 – The number of FTEs an average-sized hospital devotes to quality reporting requirements.
- $706,000 – The annual amount spent by an average-sized hospitals on administrative aspects of quality reporting.
- $760,000 – The annual amount spent by an average-sized hospital to meet Meaningful Use (MU) administrative requirements.
- 63% - The report found that over 63% of compliance costs are dedicated to compliance with documenting CoP adherence and billing and coverage verification processes.
AHA Recommends Immediate Actions
The report lists twelve immediate activities that should be taken by Congress and the Administration to “reduce regulatory burden and enhance care coordination, without negatively impacting patient care.”
Among the recommendations, two specific recommendations would definitely relieve regulatory burden for Hospital Case Managers.
- Modify Medicare CoP to allow hospitals to recommend post-acute care providers, and
- Remove the mandatory free-text field from the Medicare Outpatient Observation Notice (MOON) and eliminate the confusing Second Important Message from Medicare.
In keeping with the purpose to inform policymakers and lawmakers, all of the recommendations were provided by AHA in letters to President Trump, CMS and Congress.
The report ends by noting that regulations are needed to support the safe delivery of care. “However, the outsized growth of staff and resources devoted to regulatory and compliance-related functions illustrates that a step back is needed: federal agencies should review and streamline requirements to reduce overhead cost of health care and allow providers to focus on their mission of caring for patients.”
At MMP, we understand the regulatory burden our clients are faced with daily. This is why we publish our weekly e-newsletter and why our mission is Making Health Care Make Sense.
Beth Cobb
According to the Payment Accuracy.gov website “The Improper Payments and Elimination and Recovery Act of 2010 defines an “improper payment” as any payment that should not have been made or that was made in an incorrect amount under statutory, contractual, administrative, or other legally applicable requirements.
Expressed positively, a proper payment has four main attributes: right recipient, right amount, right reason, and right time. A violation of any one of any attributes may result as an “improper payment” if an agency cannot document those conditions. Furthermore, not all “improper payments” are the result of fraudulent actions or represent monetary loss to the government.”
The Comprehensive Error Rate Testing (CERT) Program calculates improper payment rates for the Medicare Fee-for-Service program. This article focuses on the CERT Program and Review Process and findings from the 2017 CERT Report.
CERT Program & Review Process
The CERT Program was implemented by CMS to measure improper payments in the Medicare Fee-for-Service (FFS) Program. For each reporting period, the CERT Program selects a stratified random sample of approximately 50,000 claims submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs (DMACs).
Medical review professionals perform complex medical reviews to determine whether a claim was paid properly under Medicare coverage, coding and billing rules. This process includes the following steps:
- Claim selection,
- Medical Record Requests,
- Review of claims by medical review professionals to determine whether a claim was paid properly under Medicare coverage, coding and billing rules,
- Assignment of Improper Payment Categories (no documentation, insufficient documentation, medical necessity, incorrect coding and other), and
- Calculation of the Improper Payment Rate.
CMS calculates a national improper payment rate and contractor specific and service specific improper rates from this stratified random sample of claims. As noted on the CMS CERT webpage, “The improper payment rate calculated from this sample is considered to reflect all claims processed by the Medicare FFS program during the report period.”
CMS notes “that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements. The CERT program cannot label a claim fraudulent.”
In a CMS Introduction to CERT download on the CMS CERT webpage, the following examples are provided specific to each improper payment category.
2017 CERT Report by the Numbers:
Annually, the Department of Health and Human Services (HHS) publishes the improper payment rate in the Agency Financial Report. CMS later publishes more detailed improper payment rate information in the form of the annual Medicare FFS Improper Payments Report and Appendices. CMS published the 2017 Medicare Fee-for-Service Supplemental Improper Payment Data Report on January 8, 2018. This report includes a review of claims submitted from July 1, 2015 through June 30, 2016.
Overall Claims Volume
- 21,120 - The number of claims sampled.
- 14,500 - The number of claims reviewed.
Accuracy & Improper Payment Rates
- 5% - The Percent Accuracy Rate representing $344.68 billion in claims.
- 5% - The Improper Payment Rate representing $36.2 billion in claims.
Common Causes of Improper Payments
- 1% - Insufficient Documentation
- 5% - Medical Necessity
- 1% - Incorrect Coding
- 7% - No Documentation
- 6% - Other
“0 or 1 Day” LOS Claims Continued Outlier
The CERT Program has reported Projected Improper Payments by Length of Stay (LOS) since the 2014 Report. While the Improper Payment Rate has dropped for “0 or 1 day” LOS claims, this group of claims continues to have the highest improper payment rate.
“0 or 1 Day” Audit Focus
The FY 2016 Office of Inspector (OIG) Work Plan included the issue of Hospital’s use of outpatient and inpatient stays under Medicare’s two-midnight rule (OEI; 02-15-00020). In December 2016, the OIG released the report, Vulnerabilities Remain Under Medicare's 2-Midnight Hospital Policy. This study was based on hospital claims and did not include a medical review. More specifically, the OIG considered inpatient claims lasting 2 midnights or longer as being “appropriate” and claims lasting less than 2 midnights to be “potentially inappropriate.”
One recommendation made to CMS by the OIG was to “conduct routine analysis of hospital billing and target for review the hospitals with high or increasing numbers of short inpatient stays that are potentially inappropriate under the 2-midnight policy.” CMS agreed and noted that its Quality Improvement Organizations are currently conducting short stay patient status reviews for the appropriateness of Part A payment.
Short Stays for Chest Pain: New LCD for Jurisdiction J
The OIG report identified chest pain as one of the most common reasons for a short inpatient stay to be “potentially inappropriate.”
Hopefully, you are aware that the MAC for Jurisdiction J Part A transitioned from Cahaba GBA to Palmetto GBA this past Monday January 29th. What you may not know is that Palmetto GBA has a One Day Stays for Chest Pain Local Coverage Determination (LCD L34551) that became active the same day. This guidance will be used by the BFCC-QIO (KEPRO) for Alabama, Georgia and Tennessee when reviewing short stay claims for chest pain.
Compliance with Short Stays
Have you tracked your short stay volume overall, by MS-DRG or Physician over time? Do you know if your hospital is an outlier? Where can you look to find these answers?
PEPPER
One resource available to hospitals is the Short-Term Acute Care PEPPER (Program for Evaluating Payment Patterns Electronic Report). The PEPPER is made available to hospitals on a quarterly basis and compares your hospital to your state, MAC Jurisdiction and the nation. One-day Stays for Medical and Surgical MS-DRGs are two of the “Target Areas” at risk for improper payments included in this report.
The PEPPER provides the following suggested interventions for high One-day Stays Hospitals:
“This could indicate that there are unnecessary admissions related to inappropriate use of admission screening criteria or outpatient observation. A sample of same- and/or one-day stay cases should be reviewed to determine if inpatient admission was necessary or if care could have been provided more efficiently on an outpatient basis (e.g., outpatient observation). Hospitals may generate data profiles to identify same- and/or one-day stays sorted by DRG, physician or admission source to assist in identification of any patterns related to same- and/or one-day stays. Hospitals may also wish to identify whether patients admitted for same- and/or one- day stays were treated in outpatient, outpatient observation or the emergency department for one or more nights prior to the inpatient admission. Hospitals should not review same- and/or one- day stays that are associated with procedures designated by CMS as “inpatient only.”
RealTime Medicare Data
Another source that can help assist you is our sister company, RealTime Medicare Data (RTMD). RTMD collects over 800 million Medicare claims annually from 23 states and the District of Columbia, and allows for searching of over 7 billion historical claims. In response to the “Two-Midnight” Policy, RTMD has available in their suite of Inpatient Hospital reports a One Day Stay Report. To give you a true picture of your “at risk” volume, this report excludes claims with a discharge status for Expired (20), left against medical advice (07), hospice (50 & 51) and /or were transferred to another Acute care facility (02). This report enables a hospital to view one day stay paid claims data by DRG and Physician to direct where audits should be focused. For further information on all that RTMD has to offer you can visit their website at www.rtmd.org.
To learn more about the CERT visit AdvanceMed’s CERT Provider Documentation Information website at https://certprovider.admedcorp.com/Home/About.
Beth Cobb
Total Knee Procedures (CPT 27447) were removed from the Medicare Inpatient Only List Effective January 1, 2018. CMS also finalized prohibiting 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.” However, these procedures remain “fair game” for review for medical necessity of the surgical procedure regardless of patient status.
CMS’s January 11, 2018 edition of MLN Connects included a new Medicare Learning Network (MLN) publication titled Major Joint Replacement (Hip or Knee) Booklet (ICN 909065). This booklet provides guidance on how to document medical necessity; ensure a complete and accurate medical record; key points for billing codes; and aids to correct billing.
CMS Focuses on Major Joint Replacement or Reattachment
Before the “how to,” it is important to understand “why” the focus on Major Joint Replacements.
Major Joint Replacement or Reattachment (MS-DRGs 469 and 470) are high volume, high cost procedures for Medicare. CMS has had Recovery Auditors, Comprehensive Error Rate Testing (CERT) Contractors, and Medicare Administrative Contractors (MACs) review claims for these MS-DRGs. “Their findings have demonstrated very high paid claim error rates among both hospital and professional claims associated with major joint replacement surgery.”
MS-DRG 470 is consistently the top surgical MS-DRG by volume for hospitals. To illustrate the volume and cost, the following table details the Jurisdiction J (JJ) MAC paid claims data for MS-DRG 470 for dates of service from July 1, 2016 through June 30, 2017.
Document Medical Necessity
CMS notes that “to avoid denial of claims…the medical records should contain enough detailed information to support the determination that major joint replacement surgery was reasonable and necessary for the patient. Progress notes should consist of more than just conclusive statements. Therefore, the medical record of the joint replacement surgical patient must specifically document a complete description of the patient’s historical and clinical findings.”
The Patient’s Medical Record
The following information should be included in a patient’s Medical Record to support that surgery was reasonable and necessary for the patient.
Patient History
The history should include information such as:
- A description of pain (onset, duration, character, aggravating, and relieving factors),
- Any limitations of specific Activities of ADLs (e.g., unable to climb steps),
- Safety issues (e.g. any falls),
- Contraindications to non-surgical treatments,
- Failed non-surgical treatments (e.g., NSAIDs, weight loss, intra-articular injections).
Physical Exam
Detailed objective findings of the joint examination should be included in the physical exam. Examples of findings include:
- Any deformity,
- Range of motion limitations,
- Crepitus,
- Effusions,
- Tenderness, and
- Gait description.
Investigations
The medical record should include the results of any applicable tests (i.e. plain radiographs and pre-operative imaging studies).
The Patient’s Hospital Record
Pre-operatively, the record should include documentation of the specific condition necessitating surgery such as osteoarthritis (mild, moderate, severe), avascular necrosis of the knee, or fractures).
Post-Operatively, the record should include the operative report (including observed pathology), daily progress notes for an inpatient, the discharge plan and discharge orders.
The booklet goes on to provide examples of a medical record that may result in a denied claim and a claim with more detail and support of medical necessity. CMS also provides a link to MLN SE1236 - Documenting Medical Necessity for Major Joint Replacement (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se1236.pdf) as a resource for providing guidance on documenting medical necessity for major joint replacement procedures.
MMP encourages you to carefully read the MLN Booklet and MLN SE1236 and share this information with your surgeons as CMS notes that “both physicians and hospitals are responsible for ensuring a complete and accurate record.”
Beth Cobb
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.
I once illustrated the myriad of Medicare contractors and affiliates that perform pre-payment and/or post-payment medical reviews as a spider’s web – a day late for a Halloween connection. There are at least a couple of reasons supporting an association between the two. First, healthcare providers would never want to be caught in the “web” of reviews (especially if the spider proves to be the cause of their demise). And secondly, as the filaments of a spider’s web connect together, there are connections between the different Medicare auditors. Medicare Administrative Contractors (MACs) may review problematic issues identified by the Comprehensive Error Rate Testing program (CERT). MACs may refer at-risk issues to other reviewers such as the Recovery Auditors (RACs) or the RACs might refer topics back to the MACs. The MACs or RACs may follow-up on overpayment issues identified by the Office of Inspector General (OIG) or the OIG may further investigate inappropriate payment issues identified by the MACs or RACs. This month’s report on new RAC and OIG review issues are perfect examples of this inter-related web of reviews.
There has not been a lot of new issues approved for Recovery Audit Contractor (RAC) reviews in the last month. HMS, the Region 4 Recovery Auditor, appears to have reposted some issues such as the complex review of medical necessity of sacral neurostimulation for outpatient hospitals. HMS also added an automated review for critical access hospital (CAH) and outpatient hospital services on October 6, 2017 – Outpatient Services Overlapping or During an Inpatient Stay. This review topic may be the result of findings of a recent report from the Office of Inspector General (OIG), which was addressed in detail in a Wednesday@One article from August. This automated issue is not yet listed on either the Cotiviti or Performant websites. There were no other newly approved issues related to hospital services for any of the RACs.
Hospital related issues have also been rare in the new updates to the OIG Work Plan the past few months. In the October updates, there is one issue that affects hospitals. The OIG will be reviewing supporting documentation to determine whether bariatric services meet the conditions for coverage and are supported in accordance with Federal requirements (Social Security Act, §§ 1815(a) and 1833(e)) and in keeping with the CMS National Coverage Determination (NCD) 100.1. Medicare Parts A and B only cover certain bariatric procedures when the patient meets the following criteria:
- a body mass index of 35 or higher,
- at least one comorbidity related to obesity, and
- had previously unsuccessful medical treatment for obesity.
Treatments for obesity alone are not covered. A CERT special study of bariatric surgical procedures found that approximately 98 percent of improper payments lacked sufficient documentation to support the procedures. This issue was highlighted in the July 2014 Medicare Quarterly Provider Compliance newsletter.
So even though these are new posted issues for these contractors, they are issues we have seen before.
Debbie Rubio
For over a year now, MMP has included updates to CMS transmittals and other CMS news related to acute-care hospitals as a standing article in our Wednesday@One newsletter. Do your eyes sometimes glaze over as you scan titles, numbers, dates, links, etc. or do you hear the adult-speak from the Peanuts cartoons (warnk, warnk, warnk)? I know I do, so beginning this month, we are presenting this information in a different format. We will present a single straight-forward short description of the topic of the transmittal or other update. Then if you want to know more, we provide the link to the MLN Article or other applicable document. We hope you find this new format easier to read and a better direction on what you need to know. We welcome your feed-back on our new format.
Updated Part B Drug Pricing Files
Quarterly updates to the ASP Medicare Part B Drug Pricing files.
New Waived Tests
New waived laboratory tests approved by the FDA for performance in a waived laboratory.
NPI for CWF Provider Queries
Beginning January 2018, the CWF Provider Queries will only accept NPIs as Valid Provider Numbers.
Correction to Transfer Payment for MS-DRG 385
CMS is correcting the FISS IPPS Pricer for correct calculation of transfer payments for DRB 385.
2018 ICD-10-CM POA Exempt Codes Available
The 2018 ICD-10-CM Present on Admission (POA) Exempt Codes are posted on the 2018 ICD-10-CM and GEMs webpage.
Updated Editing of Always Therapy Services
Revised editing of “always therapy” services to require the appropriate therapy modifier in order for the service to be accurately applied to the therapy cap.
NCD 20.8.4 for Leadless Pacemakers
Effective January 1, 2018, Medicare will cover leadless pacemakers when provided in a CMS-approved study.
Provider-Based Determination
Beginning November 6, 2017, MACs are required to use a uniform electronic Provider-Based (PB) checklist to perform uniform reviews of provider-based applications.
HCPCS Codes Used for SNF CB Enforcement
Quarterly (October 1, 2017) update to the list of HCPCS codes that are subject to the Consolidated Billing provision of the SNF Prospective Payment System.
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Fiscal Year (FY) 2018
Updates to the Medicare Claims Processing Manual based on the IPF PPS final rule for FY 2018 (October 1, 2017 – September 30, 2018)
Quarterly Influenza Virus Vaccine Code Update – January 2018
Quarterly update to flu vaccine codes. Effective January 2018, there is one new influenza virus vaccine code: 90756
ICD-10 Coding Revisions to National Coverage Determinations (NCDs)
Periodic updates of claim processing edits based on ICD-10 coding for NCDs. Watch these carefully as they may affect which ICD-10 codes support medical necessity for the involved services.
ICD-10 GEMS for 2018 Available
The 2018 General Equivalence Mappings (GEMs) are available:
- Diagnosis: 2018 ICD-10-CM and GEMs webpage
- Procedures: 2018 ICD-10-PCS and GEMs webpage
This is the last year that the GEMs will be produced. The 2018 ICD-10-CM Guidelines and Conversion Table will be posted once the Centers for Disease Control and Prevention finalizes them.
Inpatient Prospective Payment System (IPPS) Final Rule
The IPPS final rule was published in the Federal Register on Monday, August 14, 2017. The rule finalizes 2018 payment and policy updates for Medicare hospital admissions.
https://www.gpo.gov/fdsys/pkg/FR-2017-08-14/pdf/2017-16434.pdf
ICD-10-CM Official Guidelines for Coding and Reporting
National Center for Health Statistics (NCHS) published new coding and reporting guidelines for using ICD-10 for fiscal year 2018.
https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf
Credentials of Reviewers
This transmittal instructs Medicare reviewers (MACs, CERT, RACs, and ZPICs) to ensure complex reviews for coverage determinations are performed by Registered Nurses (RNs), therapists or physicians.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R737PI.pdf
Medicare Parts A & B Appeals Process Booklet
A new MLN booklet (June 2017) describes the appeals process, including the latest changes to the appeals process.
Influenza Vaccine Payment Allowances - Annual Update for 2017-2018 Season
Provides the Medicare Part B payment allowances for influenza vaccines for August 1, 2017-July 31, 2018.
Claim Status Category and Claim Status Codes Update
Updates, as needed, the Claim Status and Claim Status Category Codes for electronically submitted health care claims status requests and responses to explain the status of submitted claim(s).
Enforcement of the Partial Hospitalization Program (PHP) 20 Hours per Week Billing Requirement - Rescinded
MLN Matters Article SE1307 was rescinded on August 18, 2017.
Prohibition on Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program – Revision
Revision on August 23, 2017 about system changes to identify the QMB status and exemption from Medicare cost sharing, ways to promote compliance with QMB billing rules, and reminder on Medicare bad debt.
Proposed Rule- Medicare Program; Cancellation of Advancing Care Coordination Through Episode Payment and Cardiac Rehabilitation Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement Payment Model (CMS-5524-P)
Proposal to cancel the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) incentive payment model and to revise certain aspects of the Comprehensive Care for Joint Replacement (CJR) model.
Provider Error Rate Formula
Instructs Medicare Administrative Contractors (MACs) to include claims denied due to no response to additional documentation requests (ADRs) when calculating the provider error rate.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R738PI.pdf
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