Knowledge Base Article

Medicare news over the past month includes some coverage updates, ICD-10 coding updates, and clarification articles on substance abuse services and prolonged infusions.

Transmittals

Clarification of Inpatient Psychiatric Facilities (IPF) Requirements for Certification, Recertification and Delayed/Lapsed Certification and Recertification

• Transmittals 223 and 98, Change Request 9522, MLN Matters Article MM9522
• Issued May 13, 2016, Effective August 15, 2016, Implementation August 15, 2016
• Affects physicians and other specified providers submitting claims to Medicare Administrative Contractors (MACs) to certify and recertify the medical necessity of inpatient psychiatric services provided to Medicare beneficiaries.

Summary of Changes: This Change Request is to clarify physician certification, recertification and delayed//lapsed certification and recertification with respect to IPF services in Medicare Benefit Policy Manual, Chapter 2, §30.2.1.

Coding Revisions to National Coverage Determinations (NCDs)

• Transmittal 1665, Change Request 9631, MLN Matters Article MM9631
• Issued May 13, 2016, Effective October 1 2016, Implementation October 3, 2016
• Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary of Changes: This change request (CR) is the 7th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs).

Update to Internet-Only-Manual Publication 100-04, Chapter 18, Section 30.6

• Transmittal 222, Change Request 9606,MLN Matters Article MM9606
• Issued May 13,, 2016; Effective: June 14, 2016; Implementation Date June 14, 2016
• Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for cervical cancer screening services provided to Medicare beneficiaries.

Summary of Changes: This change request replaces ICD-10 diagnosis code Z12.92 with ICD-10 diagnosis code Z12.72 for coverage of cervical cancer screening in Pub. 100-04, chapter 18, section 30.6. In addition, section 30.6 is revised and updated for clarity.

Coding Revisions to National Coverage Determinations

• Transmittal 1658, Change Request 9540,MLN Matters Article MM9540
• Issued April 29, 2016; Effective July 1, 2016; Implementation Date July 5, 2016
• Affects physicians, providers, and suppliers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries

Summary of Changes: Transmittal 1630, dated February 26, 2016, is being rescinded and replaced by Transmittal 1658 to (1) remove duplicate spreadsheet NCD210.3, (2) add missing spreadsheet NCD20.33, (3) add B/MAC to requirement 3 at request of WPS/B, (4) rename the spreadsheet titles, and, (5) provide a link to the attached spreadsheets for more efficient ease of reference and accessibility. All other information remains the same.

Percutaneous Left Atrial Appendage Closure (LAAC)

• Transmittals 3515 and 192; Change Request 9638, MLN Matters Article MM9638
• Issued May 6, 2016; Effective February 8, 2016; Implementation Date October 3,, 2016
• Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary of Changes: The purpose of this Change Request (CR) is to inform contractors that the Centers for Medicare & Medicaid Services (CMS) issued a National Coverage Determination (NCD) covering Percutaneous Left Atrial Appendage Closure ( LAAC) through Coverage with Evidence Development (CED) when LAAC is furnished in patients with Non-Valvular Atrial Fibrillation (NVAF) and according to an FDA approved indication for percutaneous LAAC with an FDA-approved device.

Shared Savings Program (SSP) Accountable Care Organization (ACO) Qualifying Stay Edits

• Transmittal 1660, Change Request 9568, MLN Matters Article MM9568
• Issued May 6, 2016; Effective January 1, 2017; Implementation Date January 3, 2017
• Affects Hospitals and Skilled Nursing Facilities (SNFs) working with Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (SSP) and submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary of Changes: This CR is to allow the processing of Skilled Nursing Facility (SNF) claims without having to meet the 3-day hospital stay requirement for a select number of facilities that have a relationship with a Shared Savings Program (SSP) ACO.

Stem Cell Transplantation for Multiple Myeloma, Myelofibrosis, Sickle Cell Disease, and Myelodysplastic Syndromes

• Transmittals 3509 and 191, Change Request 9620,MLN Matters Article MM9620
• Issued April 29, 2016; Effective: January 27, 2016; Implementation date October 3, 2016
• Affects physicians and providers submitting stem cell transplantation claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

Summary of Changes: Effective for claims with dates of service on and after January 27, 2016, contractors shall be aware that the use of allogeneic HSCT for treatment of Multiple Myeloma, Myelofibrosis, and Sickle Cell Disease is only covered by Medicare if provided in the context of a Medicare-approved clinical study meeting specific criteria under the CED paradigm. This CR also clarifies the ICD-9 and ICD-10 diagnosis codes for allogeneic HSCT for treatment of Myelodysplastic Syndromes in the context of a Medicare-approved, prospective clinical study under the CED paradigm.

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/ Biological Code Changes - July 2016 Update

• Transmittal 3518; Change Request 9636; MLN Matters Article MM9636
• Issued May 6, 2016; Effective July 1, 2016; Implementation July 5, 2016
• Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment MACs (DME MACs) and Home Health & Hospice (HH&H) MACs for services provided to Medicare beneficiaries.

Summary of Changes: The HCPCS code set is updated on a quarterly basis. This instruction informs the contractors of updating specific drug/biological HCPCS codes.

JW Modifier: Drug amount discarded/not administered to any patient

• Transmittal 3508; Change Request 9603; MLN Matters Article MM9603
• Issued April 29, 2016; Effective July 1, 2016; Implementation July 5, 2016
• Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for drugs or biologicals administered to Medicare beneficiaries.

Summary of Changes: Effective July 1, 2016, claims for discarded drug or biological amount not administered to any patient, shall be submitted using the JW modifier. Also, effective July 1, 2016, providers must document the discarded drugs or biologicals in patient's medical record. This CR updates the Section 40 - Discarded Drugs and Biologicals of Chapter 17 of the Claims Processing Manual 100-04.

Medicare Coverage of Substance Abuse Services

• MLN Matters Article SE1604
• Issued April 28, 2016
• Affects physicians, other providers, and suppliers who submit claims to Medicare Administrative Contractors (MACs) for substance abuse services provided to Medicare beneficiaries.

Summary of Changes: While there is no distinct Medicare benefit category for substance abuse treatment, such services are covered by Medicare when reasonable and necessary. The Centers for Medicare & Medicaid Services (CMS) provides a full range of services, including those services provided for substance abuse disorders. This article summarizes the available services and provides reference links to other online Medicare information with further details about these services.

Medicare Policy Clarified for Prolonged Drug and Biological Infusions Started Incident to a Physician's Service Using an External Pump

• MLN Matters Article SE1609
• Issued April 25, 2016
• Affects all physicians and hospital outpatient departments submitting claims to Medicare Administrative Contractors (MACs) for prolonged drug and biological infusions started incident to a physician's service using an external pump.

Summary of Changes: Reviews policy for prolonged drug and biological infusions started incident to a physician's service using an external pump. These services cannot be billed on suppliers’ claims to DME MACs.

Other Updates

Recovery Audit Program Update

• May 4, 2016
• CMS has revised the method used to calculate additional documentation request (ADR) limits for Institutional Providers (Facilities). A document describing the new methodology can be found in the “Downloads” section of our Provider Resource

Quality Measure Development Plan

• Posted May 2, 2016
• A strategic framework for clinician quality measurement development to support the new Merit-based Incentive Payment System (MIPS) and advanced alternative payment models (APMs).

Extending Participation in the Bundled Payments for Care Improvement Initiative

• Posted April 18, 2016
• Offers the awardees in the Bundled Payments for Care Improvement (BPCI) initiative the opportunity to extend their participation in Models 2, 3 and 4 through September 30, 2018.
• http://innovation.cms.gov/initiatives/bundled-payments