Knowledge Base Category -
MEDICARE TRANSMITTALS – RECURRING UPDATES
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
The Social Security Act requires that payment for home health services provided under a home health plan of care is made to the home health agency (HHA). CMS periodically updates the lists of HCPCS codes that are subject to the consolidated billing provision of the Home Health Prospective Payment System (HH PPS).
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)
NCD coding changes as a result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.0, Effective January 1, 2019
Annual Update to the Per-Beneficiary Therapy Amounts
Describes the annual per-beneficiary incurred expense amounts now known as the KX modifier thresholds, and related policy updates for CY 2019. These amounts were previously associated with the financial limitation amounts that were more commonly referred to as “therapy caps” before the application of the therapy limits/caps was repealed by the Bipartisan Budget Act of 2018 (BBA of 2018). Another provision of the BBA of 2018 lowers the threshold of the targeted medical review process as explained in the Background section below.
For CY 2019, the KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined is $2,040. For occupational therapy (OT) services, the CY 2019 threshold amount is $2,040.
Calendar Year (CY) 2019 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Claim Status Category and Claim Status Codes Update
January 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.0
OTHER MEDICARE TRANSMITTALS
New Modifier for Expanding the Use of Telehealth for Individuals with Stroke
Establishes use of a new HCPCS modifier, G0 (G Zero), to be appended on claims for telehealth services that are furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.
Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List
Provides a summary of policies in the Calendar Year (CY) 2019 MPFS Final Rule and announces the Telehealth Originating Site Facility Fee payment amount and makes other policy changes related to Medicare Part B payment.
Revision of Definition of the Physician Supervision of Diagnostic Procedures, Clarification of DSMT Telehealth Services, and Establishing a Modifier for Expanding the Use of Telehealth for Individuals with Stroke
Updates to the Inpatient Psychiatric Facility Benefit Policy Manual
Medical Review of Diagnostic Laboratory Tests
Add instructions to chapter 6 of the Program Integrity Manual regarding medical review of diagnostic laboratory tests.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R850PI.pdf
Guidance for Medicare Administrative Contractors (MACs) Processing Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIO) Two-Midnight (2MN) Short Stay Review (SSR) Determinations
Clarifies MAC follow up actions when they receive the BFCC-QIO Short Stay Review Denial Determinations.
Revisions to Medicare Claims Processing Manual Reference to Burn Medicare Severity-Diagnostic Related Groups (MS-DRGs) for Transfer Policy
Clarifies that burn MS-DRGs 927-935 (burns -transferred to another acute care facility) are subject to the transfer payment policy.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4166CP.pdf
Targeted Probe and Educate – REVISED
Clarifies language to more accurately reflect that the new review probe must be for services/items furnished 45 days after the 1:1 education, and not just the submission date of the claim.
MEDICARE SPECIAL EDITION ARTICLES
New Medicare Webpage on Patient Driven Payment Model (for Skilled Nursing Facilities)
This newsletter generally focuses on Medicare information for acute care hospitals, but since some hospitals own or are affiliated with SNFs, we are including this item. The PDPM represents a major change in the case-mix classification model for determining SNF Part A payment.
New Medicare Beneficiary Identifier (MBI) Get It, Use It – REVISED
Revised on December 10, 2018, to update the language regarding when MACs can return an MBI through the MBI look up tool.
New Search Features Added to Fiscal Intermediary Shared System (FISS)/Direct Data Entry (DDE)
A translator tool and a search option are being added to the FISS/DDE inquiries menu options in January 2019. The translator tool is designed to display either a FISS DCN or an invoice number from an overpayment demand letter. The DDE system now has a search feature that allows the provider to search for a specific claim using the FISS DCN.
MEDICARE COVERAGE UPDATES
NCD 20.4 Implantable Cardiac Defibrillators (ICDs)
CMS’s final decision dated February 15, 2018, regarding the reconsideration of NCD 20.4, Implantable Defibrillators (ICDs). Effective February 15, 2018, coverage policy is no longer contingent on participation in a trial/study/registry. Therefore, claims with a Date of Service (DOS) on an after February 15, 2018, no longer require any trial-related coding.
National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)
Effective March 16, 2018, CMS covers diagnostic laboratory tests using next generation sequencing when specific requirements are met.
MEDICARE PRESS RELEASES
New Online Tool Displays Cost Differences for Certain Surgical Procedures
A new online tool that allows consumers to compare Medicare payments and copayments for certain procedures that are performed in both hospital outpatient departments and ambulatory surgical centers. The Procedure Price Lookup tool displays national averages for the amount Medicare pays the hospital or ambulatory surgical center and the national average copayment amount a beneficiary with no Medicare supplemental insurance would pay the provider.
OTHER MEDICARE UPDATES
Additional Frequently Asked Questions Regarding Requirements for Hospitals To Make Public a List of Their Standard Charges via the Internet
Assessing Inpatient Hospital Billing for Medicare Beneficiaries
New OIG Work Plan issue: OIG will conduct a two-part study to assess inpatient hospital billing. The first part will analyze Medicare claims data to provide landscape information about hospital billing. OIG will determine how inpatient hospital billing has changed over time and describe how inpatient billing varied among hospitals. We will then use the results of this analysis to target certain hospitals or codes for a medical review to determine the extent to which the hospitals billed incorrect codes.
https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000332.asp
It’s hard to believe that Thanksgiving is almost two weeks ago now and there are only nineteen shopping days left until Christmas. CMS provided what one could potentially call a gift depending on your point of view when they finally published Change Request (CR) 10865 on November 21st related to the ICD Final Decision Memo published early this year.
Background
CMS posted a Final Decision Memo on February 15, 2018 for the National Coverage Determination (NCD) for Implantable Automatic Defibrillators (20.4). The Decision Memo finalized what CMS described as “minimal changes” to the ICD NCD from the 2005 reconsideration.
Decision Memo: Summary of the Changes
Patient Criteria
- Add cardiac magnetic resonance imaging (MRI) to the list of diagnostic imaging studies that can evaluate left ventricular ejection fraction (LVEF).
- Note: Prior approved diagnostic imaging studies included echocardiography, radionuclide (nuclear medicine) imaging, and catheter angiography.
- Require patients who have severe non-ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation to have been on optimal medical therapy (OMT) for at least 3 months.
- Require a patient shared decision making (SDM) interaction prior to ICD implementation for certain patients.
- Note: This includes all patient’s receiving an ICD for primary prevention.
Additional Patient Criteria
- Remove the Class IV heart failure requirement for cardiac resynchronization therapy (CRT)
Exceptions to Waiting Periods
- Add an exception for patients meeting CMS coverage requirements for cardiac pacemakers, and who meet the criteria for an ICD;
- Add an exception for patients with an existing ICD and qualifying replacement
- End the data collection requirement
November 21, 2018: CMS Releases Change Request (CR) 10865
Chapter 13, section 13.1.1 of the Medicare Program Integrity Manual indicates “the decision outlined in the Coverage Decision Memo will be implemented in a CMS- issued program guidance instruction within 180 days of the end of the calendar quarter in which the memo was posted on the Web site.” The end of September came and went with no program guidance.
CMS finally published CR 10865 on November 21, 2018. This CR includes updates made to the Medicare National Coverage Determinations Manual, Chapter 1, Part 1 for NCD 20.4 Implantable Cardioverter Defibrillators (ICDs).
It is important to note that “a subsequent CR will be released at a later date that contains a Pub.100-04 Claims Processing Manual update with accompanying instructions. Until that time, the Medicare Administrative Contractors (MACs) shall be responsible for implementing NCD 20.4.”
Shared Decision Making, a Deeper Dive
A significant portion of the February Decision Memo was dedicated to detailing public comments received and CMS responses. The following table highlights comments and responses specific to the new SDM criteria.
In addition to the example SDM tool for ICDs, CMS made note of a website for patients with heart failure designed to lead them through information on ICDs to increase knowledge of their medical condition, the risks and benefits of available treatments and to empower the patient to become more involved in the decision-making process. https://patientdecisionaid.org/icd/.
Considerations Moving Forward
All patients receiving an ICD for primary prevention must be provided SDM. “For these patients…a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1)) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in §1861(aa)(5)) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision making encounter may occur at a separate visit.”
Questions to Consider:
- Who will be the healthcare provider to provide the SDM encounter?
- What tool will you utilize?
- When will this SDM be done? For example, the patient meeting Pacemaker and ICD indications that has been admitted for an AMI, Stent or CABG and placement is advised prior to the patient’s discharge.
- Since the SDM encounter can occur at a separate visit, what will be your process to make sure this information makes it into the medical record for the patient undergoing an ICD placement?
Optimal Medical Therapy, a Deeper Dive
Patients who have severe non-ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation must have been on optimal medical therapy (OMT) for at least 3 months prior to ICD placement. The following table highlights comments and responses specific to the new OMT criteria.
Questions to Consider:
- Who is the healthcare provider providing optimal medical therapy? Is it a patient’s Internal Medicine Doctor, Cardiologist, Electrophysiologist?
- Similar to SDM, what will be your process to make sure this information makes it into the medical record when the patient receives an ICD?
CR Implementation Date: February 26, 2019
It is up to you to decide if the 2019 implementation date is an early gift from CMS or a potential lump of coal for those that have not begun to prepare for the changes. Either way, MMP will be on the lookout for the subsequent Change Request specific to the Medicare Claims Processing Manual and accompanying instructions and encourages key stakeholders to put processes in place now to meet the new NCD requirements.
One of my grandchildren’s favorite books is “It Could Be Worse.” This book follows the trip home of a young mouse from visiting friends. The mouse experiences one calamity after another – he falls in a hole, tumbles down a bank, falls into a stream, etc. The young mouse believes he is having a very bad day, but the illustrations show that he is actually narrowly escaping real disasters due to his minor mishaps. He falls in the hole just as a large predatory bird swoops down to grab him, for example. Sometimes we think things are bad, but generally they could always be worse.
Over the past couple of weeks, we have included articles in the Wednesday@One about the Outpatient Prospective Payment System (OPPS) Final Rule. For most of our hospital clients and readers, your outpatient services are paid under OPPS. There are some services however that, even for OPPS hospitals, are paid under a fee schedule other than OPPS. These services are identified on the OPPS Addendum B with a status indicator (SI) of “A” – “Not paid under OPPS. Paid by MACs under a fee schedule or payment system other than OPPS.” Along with the payment systems often come payment rules for these services that also apply to hospital billing. Hospitals have to look to the Medicare Physician Fee Schedule (MPFS) Final Rule for some of these additional requirements. This week we examine some of the rule changes from the MPFS rule for 2019 that affect hospitals, including some changes that will not become effective until next year.
Off-Campus Provider Based Departments
Non-excepted off-campus provider-based departments (PBDs), that is those off-campus PBDs that began billing and furnishing services on or after November 2, 2015, are paid under the MPFS instead of under OPPS due to Section 603 of the Bipartisan Budget Act of 2015. Currently Medicare sets the MPFS rates for non-excepted off-campus PBDs annually in the MPFS final rule. This year, CMS finalized their “proposal to maintain the PFS Relativity Adjuster at 40 percent for CY 2019 and beyond until there is an appropriate reason and process for implementing an alternative to our current policy, at which time we will make a proposal through notice and comment rulemaking.” This means services in a non-excepted off-campus PBD will be paid at 40% of the OPPS payment rate for 2019 and beyond until Medicare elects to use a different payment policy for these services. Currently, OPPS packaging and payment rules also apply, including this year the reduced payment of ASP minus 22.5% for separately payable outpatient drugs (SI=”K”) purchased through the 340B program.
Therapy Services
Medicare is ending the requirements for reporting and documentation of functional limitation G codes (HCPCS codes G8978 through G8999 and G9158 through G9186) and severity modifiers (in the range CH through CN) for outpatient therapy claims with dates of service on and after January 1, 2019. This means physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) no longer have to report the functional limitation codes and modifiers beginning the first of the new year. CMS is not deleting these G codes until 2020 so that claims will not return or reject if they inadvertently contain these codes.
The Bipartisan Budget Act of 2018 contained requirements for reduced payments for therapy services furnished in whole or in part by therapy assistants. The payment reductions do not begin until 2022 and reporting requirements to identify such services do not begin until 2020. There is nothing to deal with this year, but here are some points to be aware of for the future.
- Reporting and payment reduction will apply to hospital outpatient therapy services (except for critical access hospitals).
- Payment for therapy services furnished on or after January 1, 2022, in whole or in part by a therapy assistant, will be paid at 85% of the otherwise applicable Part B payment amount for the service.
- Since there are no therapy assistants for Speech Language Pathology (SLP) services, this only applies to physical therapy assistants and occupational therapy assistants.
- CMS is creating two new modifiers to be appended to PT and OT line items furnished in whole or in part by a therapy assistant beginning with dates of service on and after January 1. 2020 (although payment reduction will not occur until 2022). The new modifiers, PTA modifier CQ and OTA modifier CO, will be reported alongside of the existing GP and GO modifiers.
- CMS considers a service to be furnished in whole or in part by a PTA or OTA when more than 10% of the service is furnished by the PTA or OTA.
Laboratory Services
Most laboratory services on OPPS Addendum B have an SI of “Q4” due to the OPPS packaging requirements. However, when lab services meet the criteria for separate payment (i.e. they are the only type of service billed on the claim), they are paid separately under the Clinical Lab Fee Schedule (CLFS). The Protecting Access to Medicare Act of 2014 (PAMA), made significant changes to how Medicare pays for clinical diagnostic laboratory tests under the CLFS. Beginning January 1, 2018, CLFS rates are based on private payor rates reported to CMS by applicable laboratories. Not many hospital laboratories met the definition of an applicable reporting laboratory because it was defined as an entity that receives more than 50 percent of its Medicare revenues during a data collection period from the CLFS and/or the Physician Fee Schedule (PFS). Unless a hospital lab had its own NPI separate from the hospital NPI, it was unlikely the percent of CLFS/MPFS revenues was enough to meet the definition.
This year, Medicare is changing the definition to use Form CMS-1450 14x type of bill (TOB) to define applicable laboratories for the next data collection period (January 1, 2019, through June 30, 2019) and the next data reporting period (January 1, 2020, and ends March 31, 2020), subject to other regulatory and subregulatory requirements, such as the regulatory low expenditure threshold. Hospital outreach laboratories that do not receive at least $12,500 in CLFS revenues on the 14X TOB during a data collection period (6 months) would be exempt from the reporting requirements. This means more hospital laboratories will now be required to report private payor lab rates to CMS, specifically those hospital outreach labs with more than $12,500 in CLFS revenues per six months. Hospitals need to evaluate whether they meet the new criteria for reporting and if so, be prepared to report by 2020.
Appropriate Use Criteria for Advanced Imaging
Imaging services are paid under OPPS, but there are new rules coming for 2020 that affect hospitals also. PAMA also directed CMS to establish a program to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging services. Under the program, ordering professionals must consult specified applicable appropriate use criteria (AUC) using a qualified clinical decision support mechanism (CDSM) when ordering applicable imaging services, and furnishing professionals must report AUC consultation information on the Medicare claim. Reporting is required beginning January 1, 2020. Year 2020 is an educational and operations testing period during which AUC consultation information is expected to be reported on claims, but claims will not be denied for failure to include the information. Reporting is required across claim types and by both the furnishing professional and furnishing facility, including hospital outpatient facilities (inpatient services paid under Part A are exempted). A lot more details on AUC can be found in the MPFS Final Rule. Since reporting is not required until 2020, hospitals have time to prepare. We will provide more details prior to the 2020 reporting requirement.
That is a summary of some changes from the MPFS Final Rule that affects hospitals. A couple of issues that you do not have to worry about until next year – reporting new modifiers for therapy assistants and reporting AUC information for advanced imaging services. This year your non-excepted off-campus PBDs will continue to be paid at 40% of OPPS rates, functional limitation reporting for therapy services goes away, and you need to decide if your outreach laboratory meets the definition of an applicable lab for reporting private payor lab rates to Medicare. Not a lot of things from the MPFS to consider, …yet – it could be worse.
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
January 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Update to Medicare Deductible, Coinsurance and Premium Rates for 2019
International Classification of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – REVISED
A maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs) as a result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2202OTN.pdf
OTHER MEDICARE TRANSMITTALS
Incomplete Colonoscopies Billed with Modifier 53 for Critical Access Hospital (CAH) Method II Providers
Implements the payment methodology for incomplete colonoscopy procedures (Healthcare Common Procedure Coding System (HCPCS) codes 44388, 45378, G0105, and G0121 with a modifier 53) for CAH Method II providers.
Correction to Common Working File (CWF) Informational Unsolicited Response (IUR) 7272 for Intervening Stay
Correction to edit for IPPS hospital claim with patient discharge status code ‘61’ (Discharged/transferred within this institution to a hospital-based Medicare approved swing bed) and a home health claim is received with an admission date equal to or within 3 days of the history IPPS claim’s discharge date and there is an intervening swing bed claim in history.
Hospital and Critical Access Hospital (CAH) Swing-Bed Manual Revisions
Clarifies policies related to hospitals and CAHs with respect to services furnished to swing-bed patients, including policies related to pass-through reimbursement for Certified Registered Nurse Anesthetist (CRNA) services.
Update to Bone Mass Measurements (BMM) Code 77085 Deductible and Coinsurance
Instructs contractors to waive deductible and coinsurance for BMM code 77085.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4150CP.pdf
Removal of the Provider Requirement for Reporting on an Institutional Claim a Value Code (VC) 05 - Professional Component-Split Implementation
Removes editing for the requirement of value code 05 on an institutional claim.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2178OTN.pdf
User CR: Fiscal Intermediary Shared System (FISS) - Implementation of the Molecular Diagnostic Services (MolDX)
Adds a MolDX test identification (ID) field to FISS so providers will be able to input a unique test ID into their claims at the detail line level.
Common Working File (CWF) Provider Queries National Provider Identifier (NPI) and Submitter Identification (ID) Verification
The Common Working File (CWF) will require verification of the National Provider Identifier (NPI) and Submitter Identification (ID) when Medicare Part A providers request Medicare beneficiary eligibility and entitlement data via the CWF provider inquiry screens.
MEDICARE PRESS RELEASES
CMS finalizes Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System changes for 2019 (CMS-1695-FC)
Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Cochlear Devices Replaced Without Cost
- Reporting Changes in Ownership
- Ophthalmology Services: Questionable Billing and Improper Payments
November Patients Over Paperwork Newsletter
Updates on the Administration’s ongoing work to reduce administrative burden and improve the customer experience for beneficiaries.
https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/PoPNovember2018.pdf
Medicare Billing: Form CMS-1450 and the 837 Institutional Educational Booklet
CERT Article on Patient Discharge Codes
OTHER MEDICARE UPDATES
Medicare Letter to Clinicians
Outlines how the agency is reducing burden through reform of documentation and coding requirements.
Contract Award for A/B MAC Jurisdiction 8
On November 1, 2018, CMS awarded Wisconsin Physicians Service Government Health Administrators (WPS) (the incumbent contractor for this A/B MAC jurisdiction) a new contract for the administration of Medicare Part A and Part B Fee-for-Service (FFS) claims in the states of Indiana and Michigan.
MEDICARE TRANSMITTALS – RECURRING UPDATES
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2019
The January 2019 quarterly release of the edit module for clinical diagnostic laboratory services.
Quarterly Influenza Virus Vaccine Code Update - January 2019
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4141CP.pdf
2019 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
Updates to edits to allow only those services that are excluded from SNF CB to be paid separately.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 1st Qtr Notification for FY 2019
The Medicare contractors shall implement an interest rate of 10.125 percent effective October 17, 2018 for Medicare overpayments and underpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R307FM.pdf
OTHER MEDICARE TRANSMITTALS
Implementation of the Award for the Jurisdiction F (J-F) Part A and Part B Medicare Administrative Contractor (JF A/B MAC)
The Jurisdiction JF A/B MAC recompetition procurement was recently awarded to Noridian Healthcare Solutions, LLC (Noridian), the incumbent contractor for this workload.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2143OTN.pdf
Guidance Regarding the Use of Statistical Sampling for Overpayment Estimation
Updates instructions for Unified Program Integrity Contractors (UPICs), Recovery Audit Contractors (RACs), the Supplemental Medical Review Contractor (SMRC), and Medicare Administrative Contractors (MAC) regarding the use of statistical sampling in their reviews and estimation of overpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R828PI.pdf
Local Coverage Determinations (LCDs)
CMS is updating the Medicare Program Integrity Manual with detailed changes to the Local
Coverage Determination (LCD) process.
Fiscal Year (FY) 2019 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Changes
Implements Fiscal Year (FY) 2019 policy changes for the Inpatient Prospective Payment System (IPPS) and LTCH PPS.
Updating Calendar Year (CY) 2019 Medicare Diabetes Prevention Program (MDPP) Payment Rates
This MLN Matters Article is intended for organizations enrolled as Medicare Diabetes Prevention Program (MDPP) suppliers billing Medicare Administrative Contractors (MACs) for MDPP services provided to Medicare beneficiaries.
Medical Review of Diagnostic Laboratory Tests
Clarifies how medical review contractors should review orders for diagnostic laboratory test claims.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R836PI.pdf
MEDICARE SPECIAL EDITION ARTICLES
Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations
Medicare systems will validate service facility location to ensure services are being provided in a Medicare enrolled location based on the information submitted on the Form CMS-855A submitted by the provider and entered into the Provider Enrollment, Chain and Ownership System (PECOS).
2018-2019 Influenza (Flu) Resources for Health Care Professionals
MEDICARE COVERAGE UPDATES
Magnetic Resonance Imaging (MRI)
Effective for claims with dates of service on and after April 10, 2018, Medicare will allow for MRI coverage for beneficiaries with an Implanted Pacemaker (PM), Implantable Cardioverter Defibrillator (ICD), Cardiac Resynchronization Therapy Pacemaker (CRT-P), or Cardiac Resynchronization Therapy Defibrillator (CRT-D).
MEDICARE PRESS RELEASES
2019 Medicare Parts A & B Premiums and Deductibles
The standard monthly premium for Medicare Part B enrollees will be $135.50 for 2019. The annual deductible for Medicare Part B beneficiaries is $185 in 2019. The Medicare Part A inpatient deductible that beneficiaries will pay when admitted to the hospital is $1,364 in 2019.
https://www.cms.gov/newsroom/fact-sheets/2019-medicare-parts-b-premiums-and-deductibles
MEDICARE EDUCATIONAL RESOURCES
October 2018 Medicare Quarterly Provider Compliance Newsletter
Assists health care professionals to understand the latest findings identified by MACs and other contractors such as Recovery Auditors and the Comprehensive Error Rate Testing (CERT) review contractor, in addition to other governmental organizations such as the Office of the Inspector General (OIG).
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims
OTHER MEDICARE UPDATES
September 2018 Patients Over Paperwork Newsletter
An update on CMS’s ongoing work to reduce administrative burden and improve the customer experience while putting patients first.
https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/POPSeptember2018Newsletter.pdf
MMP initially ran this article September 12, 2018, click here to read the original article. Since then CMS posted a correction to the 2019 IPPS Final Rule on October 3rd. This correction included the following important update to inpatient cases involving the drug VABOMERE™ which is available for a new technology add-on payment.
Notice in 2019 IPPS Final Rule Correction published in the Federal Register October 3, 2018:
“On page 41311, we made a typographical error in describing which National Drug Code (NDC) will be used to identify cases involving VABOMERE™ that are eligible for new technology add-on payments in FY 2019. Specifically, we are correcting the NDC code of 65293–0009–01, which erroneously was missing an extra digit. In addition, we were made aware after the final rule that NDC 70842–0120–01 can also be used to identify cases of VABOMERETM. Therefore, cases involving the use of VABOMERE™ that are eligible for new technology add-on payments in FY 2019 will be identified with either of the following NDCs: 65293–0009–01 and 70842–0120–01.”
New Technology
Melinta Therapeutics, Inc.’s application for new technology add-on payments for VABOMERE™ for FY 2019 was approved by CMS. The maximum new technology add-on payment for cases involving the use of VABOMERE™ for FY 2019 is $5,544.
What is VABOMERE™ (Meropenem-vaborbactam)?
VABOMERE™ is a combination product containing meropenem and vaborbactam. This drug is indicated for treating adult patients diagnosed with complicated urinary tract infections (cUTIs), including pyelonephritis caused by the following susceptible microorganisms: Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae species complex.
Issue
There is no unique ICD-10-PCS procedure code for VABOMERE™ for FY 2019 leaving hospitals with no way to uniquely identify the use of VABOMERE™ on an inpatient claim.
How to identify the use of VABOMERE™ on an Inpatient Claim
CMS revised their policy to allow the use of an alternative code set to identify an oral medication when there is no inpatient procedure code for purposes of new technology add-on payments in the FY 2013 IPPS Final Rule. Specifically, they adopted the National Drug Code (NDC) as an alternative code set to identify the use of DIFICID™ effective for discharges on or after October 1, 2012.
While VABOMERE™ is administered by IV infusion and not orally, CMS acknowledges that “it is the first approved new technology aside from an oral drug with no uniquely assigned inpatient procedure code” and believes for purposes of identifying the use of VABOMERE™ this is a similar circumstance to the use of DIFICID™.
For FY 2019, cases eligible for the FY 2019 new technology add-on payments will be identified by the NDC code 65293-0009-01 (VABOMERE™ Meropenem-Vaborbactam Vial) or NDC code 70842-0120-01. Providers must code the NDC in data element LIN03 of the 837i Health Care Claim Institutional form in order to receive the new technology add-on payment for procedures involving the use of VABOMERE™.”
Who Needs to Know this Information?
Your hospital Pharmacy should be made aware of this information so they can collaborate with your Billing Office to ensure you receive the add-on payment for eligible claims.
Resources
Billing guidance can be found on page 49837 of the October 3, 2018 Final Rule Correction Notice published in the Federal Register which can be accessed from the CMS FY 2019 IPPS Final Rule Homepage at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2019-IPPS-Final-Rule-Home-Page.html.
Additional information about VABOMERE™ can be found on the Melinta Therapeutics, Inc. website at http://www.vabomere.com/.
Beth Cobb
MEDICARE TRANSMITTALS – RECURRING UPDATES
Healthcare Provider Taxonomy Codes (HPTCs) October 2018 Code Set Update
October 2018 Integrated Outpatient Code Editor (I/OCE) Specifications Version 19.3
October updates to the I/OCE.
Claim Status Category and Claim Status Codes Update
October 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Changes, new codes, and billing instructions for various OPPS payment policies.
Influenza Vaccine Payment Allowances - Annual Update for 2018-2019 Season
Annual Clotting Factor Furnishing Fee Update 2019
Announces the clotting factor furnishing fee for 2019 is $0.220 per unit.
International Classification of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)
A maintenance update of ICD-10 conversions and other coding updates specific to NCDs.
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – October 2018 Update - REVISED
Informs MACs of the October 2018 addition of new HCPCS codes, Q5108 (Injection, fulphila) and Q5110 (Nivestym). The codes are payable by Medicare effective with dates of service on or after July 12, 2018, for Q5108 and effective with dates of service on or after October 1, 2018, for Q5110.
OTHER MEDICARE TRANSMITTALS
Update to Chapter 15, Pub. 100-08, Certification Statement Policies
Modifications to certain provider enrollment certification statement policies, specifically, allowing upload provider enrollment certification statements using PECOS functionality.
Revisions to the Telehealth Billing Requirements for Distant Site Services – REVISED
Revised to correct the effective date of the GT modifier.
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).
MEDICARE SPECIAL EDITION ARTICLES
Intensity-Modulated Radiation Therapy (IMRT) Planning Services Editing
When IMRT is paid under the hospital OPPS, hospitals must remember that CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 (IMRT planning). You should not report these codes in addition to CPT code 77301, when provided prior to, or as part of, the development of the IMRT plan. The charges for these services should be included in the charge associated with CPT code 77301, even if the individual services associated with IMRT planning are performed on dates of service other than the date on which CPT code 77301 is reported.
MEDICARE RULES
Medicare and Medicaid Programs; Proposed Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction
A proposed rule to relieve burden on healthcare providers by removing unnecessary, obsolete or excessively burdensome Medicare compliance requirements for healthcare facilities.
Provisions in the proposed rule would, for example:
- Eliminate a duplicative requirement on transplant programs to submit data and other information more than once for “re-approval” by Medicare.
- Streamline hospital outpatient and ambulatory surgical center requirements for conducting comprehensive medical histories and physical assessments.
- Allow multi-hospital systems to have unified and integrated Quality Assessment and Performance Improvement programs for all of their member hospitals.
- Simplify the ordering process for portable x-rays and modernize the personnel requirements for portable x-ray technologists.
- Remove duplicative ownership disclosure requirements for Critical Access Hospitals.
OTHER MEDICARE UPDATES
Federal Register: Changes to the Low-Volume Hospital Payment Adjustment Under the IPPS
Announces changes to the payment adjustment for low-volume hospitals under the hospital IPPS for acute care hospitals for FY 2011-2017.
https://www.gpo.gov/fdsys/pkg/FR-2018-08-23/pdf/2018-18271.pdf
Updated Guidance to Hospitals and CAHs Concerning Swing Beds
CMS is providing updated guidance to surveyors for the special requirements for Hospital and CAH providers of long-term care services (LTC), also known as “swing beds”.
MEDICARE EDUCATIONAL RESOURCES
Diabetes Self-Management Training Accrediting Organizations Fact Sheet
CMS Provider Minute Video: The Importance of Proper Documentation — Reminder
Explain importance of proper documentation and how it affects items/services, claim payment, and medical review.
https://www.youtube.com/watch?v=10pmw4czf08&feature=youtu.be
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Provider Minute Video: The Importance of Proper Documentation
- Bill Correctly for Device Replacement Procedures
Medicare Preventive Services On-Line Educational Tool
Information on Medicare preventive services that includes:
- A link to the National Coverage Determination (NCD) webpage for the service, if it applies
- HCPCS/Current Procedural Terminology (CPT) codes
- International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes
- Coverage requirements
- Frequency requirements
- Medicare beneficiary liability
New Technology
Melinta Therapeutics, Inc.’s application for new technology add-on payments for VABOMERE™ for FY 2019 was approved by CMS. The maximum new technology add-on payment for cases involving the use of VABOMERE™ for FY 2019 is $5,544.
What is VABOMERE™ (Meropenem-vaborbactam)?
VABOMERE™ is a combination product containing meropenem and vaborbactam. This drug is indicated for treating adult patients diagnosed with complicated urinary tract infections (cUTIs), including pyelonephritis caused by the following susceptible microorganisms: Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae species complex.
Issue
There is no unique ICD-10-PCS procedure code for VABOMERE™ for FY 2019 leaving hospitals with no way to uniquely identify the use of VABOMERE™ on an inpatient claim.
How to identify the use of VABOMERE™ on an Inpatient Claim
CMS revised their policy to allow the use of an alternative code set to identify an oral medication when there is no inpatient procedure code for purposes of new technology add-on payments in the FY 2013 IPPS Final Rule. Specifically, they adopted the National Drug Code (NDC) as an alternative code set to identify the use of DIFICID™ effective for discharges on or after October 1, 2012.
While VABOMERE™ is administered by IV infusion and not orally, CMS acknowledges that “it is the first approved new technology aside from an oral drug with no uniquely assigned inpatient procedure code” and believes for purposes of identifying the use of VABOMERE™ this is a similar circumstance to the use of DIFICID™.
For FY 2019, cases “eligible for the FY 2019 new technology add-on payments will be identified by the NDC of 65293-009-01 (VABOMERE™ Meropenem-Vaborbactam Vial). Providers must code the NDC in data element LIN03 of the 837i Health Care Claim Institutional form in order to receive the new technology add-on payment for procedures involving the use of VABOMERE™.”
Who Needs to Know this Information?
Your hospital Pharmacy should be made aware of this information so they can collaborate with your Billing Office to ensure you receive the add-on payment for eligible claims.
Resources
Billing guidance can be found on page 41311 of the Final Rule which can be accessed from the CMS FY 2019 IPPS Final Rule Homepage at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2019-IPPS-Final-Rule-Home-Page.html.
Additional information about VABOMERE™ can be found on the Melinta Therapeutics, Inc. website at http://www.vabomere.com/.
Beth Cobb
If you are a frequent reader of our newsletter, you often see the acronyms “OPPS” and “IPPS.” These refer respectively to the outpatient and inpatient prospective payment systems. Medicare describes a Prospective Payment System (PPS) as “a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, diagnosis-related groups (DRGs) for inpatient hospital services).” This means for a particular DRG, a hospital always receives the same payment. Well, that is, until they don’t. Under Medicare’s transfer policies, DRG payments are prorated (reduced) when a patient transfers to another hospital or to select post-acute care settings. The specific regulations regarding transfer policies can be found in Chapter 4 of the Medicare Claims Processing Manual, Section 40.2.4.
The transfer policies bring in yet another acronym - the post-acute care transfer (PACT) policy. In recent weeks, two issues have come up related to the PACT policy. Before discussing these issues, let’s do a quick review of the policy.
- PACT policy only applies to certain MS-DRGs. The list of DRGs to which the policy applies is updated annually as Table 5 of the IPPS Final Rule.
- PACT policy only applies when the patient is transferred to certain post-acute care settings:
- Inpatient rehab facilities and units (discharge status code 62)
- Long term care hospitals (code 63)
- Psychiatric hospitals and units (code 65)
- Children’s and Cancer hospitals (code 05)
- Skilled nursing facilities (code 03)
- Home with a home health plan of care that begins within 3 days (code 06)
- Medicare identifies transfers to the affected settings by the discharge status code on the claim. If Medicare receives a claim from a post-acute care provider for days immediately after discharge, they will ask the transferring hospital to adjust their discharge status code as needed.
- Payment is only reduced if a patient stays fewer days than expected in the first (transferring) hospital for a particular DRG (the geometric mean length of stay or GMLOS).
- Payment is reduced to the transferring hospital. A per diem rate is calculated by dividing the MS-DRG rate by the GMLOS. The transferring hospital is paid 2 x the per diem rate for the first day and the per diem rate for subsequent days up to the full MS-DRG payment.
- There are special pay MS-DRGs (also noted in Table 5) that are paid differently, with a higher payment percentage for the first day of hospitalization.
- Transfer cases are eligible for outlier payments
Also see MLN Matters Article SE1411 for more information about discharge status and Medicare transfer policies.
The first new PACT issue is that the 2019 IPPS Final Rule added discharges to hospice to the PACT policy. This change was made in accordance with amendments to the Social Security Act by the Bipartisan Budget Act of 2018. The new law requires a discharge to hospice care provided by a hospice program to be a qualified discharge under PACT. This means qualifying DRGs with a Patient Discharge Status code of 50 (Discharged/Transferred to Hospice—Routine or Continuous Home Care) or 51 (Discharged/Transferred to Hospice, General Inpatient Care or Inpatient Respite) are subject to the post-acute care transfer policy effective for discharges occurring on or after October 1, 2018.
The second issue related to the PACT policy is a new item added to the August update of the Office of Inspector General (OIG) Work Plan:
“Hospitals' Compliance with Medicare's Transfer Policy With the Resumption of Home Health Services and the Use of Condition Codes
Medicare payments to acute care hospitals for inpatient stays under Medicare Part A are made on the basis of prospectively set rates. Normally, Medicare pays a hospital discharging a beneficiary the full amount for the corresponding diagnosis-related group (DRG). In contrast, a hospital that transfers a beneficiary to another facility or to home health services is paid a graduated per diem rate, not to exceed the full DRG payment. When transferring a patient to home health services, the hospital can apply specific condition codes to the claim and receive the full DRG payment. The hospital is responsible for coding the bill on the basis of its discharge plan for the patient or adjusting the claim if it finds out that the patient received postacute care after the discharge. We will determine whether Medicare appropriately paid hospitals' inpatient claims subject to the postacute care transfer policy when (1) patients resumed home health services after discharge or (2) hospitals applied condition codes to claims to receive a full DRG payment.”
The PACT policy applies when patients are discharged to “home under a written plan of care for the provision of home health services from a home health agency and those services occur within 3 days after the date of discharge - Patient Discharge Status Code 06 (or 86 when an Acute Care Hospital Inpatient Readmission is planned)” with some exceptions. One exception is when the home health services are not related to the reason for the inpatient admission hospital stay. In this case, condition code 42 is reported on the claim with a discharge status code 06, and the hospital will receive full payment based on the MS-DRG and not a per diem payment. This may occur when there is a resumption of home care services the patient was receiving before hospital admission, if the reason for the home health services is not related to the reason for hospital care.
A hospital can also receive full payment if the home health services do not begin within 3 days of the inpatient discharge. If home care was started more than three days after discharge from the hospital, the hospital would report condition code 43 on the claim. Again, in this case, the hospital will receive full payment based on the MS-DRG and not a per diem payment.
Hospitals should definitely be reporting these condition codes when applicable so as to receive appropriate Medicare payments. But they also need to be sure they are using the codes correctly and only when the required conditions apply. The tricky part about discharge status coding is that the hospital staff may not always know what actually happens when the patient leaves the hospital. It is a good practice to have someone verify with the patient if and exactly what and when post-discharge care occurred. For example, if home health services were planned to begin on day 4 after discharge, but actually began on day 3, it would not be appropriate to report condition code 43. Or the reverse could happen – home health planned for day 2 but does not begin until day 4 after discharge, in which case reporting condition code 43 could result in a higher, appropriate payment.
Another key is communication between case management/discharge planners, coders, and the billing office. Case management documentation is usually the most reliable source for post-discharge plans. If something changes after discharge, and the case managers have followed up to know that, they need to amend documentation and inform the coders and billers if the account has already been coded and/or billed. One last recommendation is a compliance review of discharge status every now and then. This was a huge issue when I started in hospital compliance many years ago and as you can see by the new OIG Work Plan item, it continues to be so. Here is a list of the tips noted above plus a few more to ensure accurate discharge status coding, billing, and appropriate payments:
- Make sure coders know and understand correct use of the discharge status code,
- Make sure coders know where in the record to find the most accurate information concerning discharge status and whom to ask if they have questions,
- Have a system in place to follow up after discharge to verify what post-discharge care the patient actually received,
- Have processes for clear and timely communication between case management, coders and billers concerning discharge status,
- Have a procedure to handle Medicare requests to change discharge status (this can occur when Medicare receives claims from other hospitals or post-acute care providers for services immediately following a hospital discharge), and
- Perform periodic audits of discharge status.
Following these recommendations may prevent the OIG from NYTTW (nailing you to the wall) should your claims be audited.
Debbie Rubio
Some bundles are great – a bundle may refer to a “bundle” of money; you can have bundles of fun; or expecting parents look forward to their little bundle of joy. Other bundles – not so great. One such bundle that is not a bundle of fun is the bundled payment Medicare makes for Intensity-Modulated Radiation Therapy (IMRT) planning services. Payment bundles are fairly common in the Medicare world, but the onus is on providers to understand appropriate billing rules so they are not overpaid for bundled services. A recent Office of Inspector General (OIG) report found errors in IMRT planning billing that resulted in over $25 million in Medicare overpayments for the audit period (2013-2015). The report recommended education for providers on billing IMRT planning services correctly, and edits in Medicare’s billing system to prevent overpayments.
IMRT uses advanced computer programs to plan and deliver radiation to difficult-to-reach tumors with high precision while reducing exposure to surrounding healthy tissue. IMRT includes planning and delivery services. IMRT planning is a multistep process in which imaging, calculations, and simulations are performed to develop an IMRT treatment plan. Radiation is then delivered to a patient’s tumor at the various intensity levels prescribed in the IMRT treatment plan.
The basic rule for the bundling of IMRT planning services is found in section 200.3.1 of Chapter 4 of the Medicare Claims Processing:
- “Payment for the services identified by CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 (IMRT planning). These codes should not be reported in addition to CPT code 77301 when provided prior to or as part of the development of the IMRT plan. In addition, CPT codes 77280-77290 (simulation-aided field settings) should not be reported for verification of the treatment field during a course of IMRT.”
As evidenced by the OIG’s recommendations, the primary reasons for overpayments were that hospitals were unfamiliar with or misinterpreted CMS guidance and claim processing edits did not prevent overpayments. One of the biggest challenges for both hospitals and CMS is the bundling applies even to services billed on a different date of service than the comprehensive IMRT planning code (CPT 77301). CMS’s NCCI procedure-to-procedure edits applicable to IMRT planning services only applied to planning services billed on the same date of service as the billing of CPT code 77301 for the bundled payment. This application of bundling to different dates of service may also have caused some confusion for hospitals. The services in the OIG sample were billed on a different date of service from the IMRT planning CPT code 77301.
In analyzing payment data, the OIG noted that complex simulations billed using CPT code 77290 made up approximately 84% of the potential overpayments so that is the code they reviewed. They found that “In each case, a complex simulation was billed with CPT code 77290 on a different date of service from the IMRT planning code (i.e., up to 14 days before CPT code 77301 was billed). However, both services were performed for the same treatment site (e.g., the prostate). According to the independent medical review contractor, for each sampled line item, the complex simulation was performed as a part of the beneficiary’s overall IMRT treatment planning and therefore should not have been billed separately.”
The Claims Processing Manual guidance quoted above was updated after the OIG audit period to clarify that complex simulations are included in the APC payment for IMRT planning services “when provided prior to or as part of the development of the IMRT plan” (emphasis added). That was a step in the right direction but the OIG further recommended that CMS:
- Implement an edit to prevent improper payments for IMRT planning services that are billed before (e.g., up to 14 days before) IMRT planning CPT code 77301 is billed, and
- Work with the Medicare contractors to educate hospitals on properly billing Medicare for IMRT planning services.
Hospitals need to evaluate their billing practices for IMRT services now and verify they are not inappropriately billing separately for services included in IMRT planning. After all, a little OIG audit would not be a bundle of joy.
Debbie Rubio
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