Knowledge Base Category -

TRANSMITTALS

Implementation of New Influenza Virus Vaccine Code

• Transmittal R3617CP, Change Request 9793, MLN Matters Article MM9793
• Issued September 30, 2016, Effective August 1, 2016, Implementation January 3, 2017
• Affects physicians and providers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.
• Summary of Changes: Provides instructions for payment and edits for the common working file (CWF) to include influenza virus vaccine code 90674.

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2017

• Transmittal R3614CP, Change Request 9806, MLN Matters Article MM9806
• Issued September 23, 2016, Effective October 1, 2016, Implementation January 3, 2017
• Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
• Summary of Changes: Quarterly updates to the national coverage determinations (NCDs) for clinical diagnostic laboratory services.

Update to Hepatitis B Deductible and Coinsurance and Screening Pap Smears Claims Processing Information

• Transmittal R3615CP, Change Request 9778, MLN Matters Article MM9778
• Issued September 23, 2016, Effective December 27, 2016, Implementation December 27, 2016
• Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
• Summary of Changes: Updates erroneous information regarding coinsurance and deductible for hepatitis B virus vaccine and screening Pap smears.

Notice of New Interest Rate for Medicare Overpayments and Underpayments -1st Qtr Notification for FY 2017

• Transmittal R273FM, Change Request 9863
• Issued October 12, 2016, Effective October 18, 2016, Implementation October 18, 2016
• Summary of Changes: Quarterly update of the interest on overpayments and underpayments to Medicare providers

OTHER UPDATES

BFCC-QIOs Resuming Short-Stay Reviews

• Inpatient Hospital Reviews
• Effective September 12, 2016
• Summary of Changes: BFCC-QIOs will resume initial patient status reviews of short stays in acute care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities to determine the appropriateness of Part A payment for short stay hospital claims.

Hospital Appeals Settlement

• Inpatient Hospital Reviews
• Issued September 28, 2016
• Summary of Changes: CMS has decided to once again allow eligible providers to settle their inpatient status claims currently under appeal using the Hospital Appeals Settlement process. Specific details of the settlement will be released in the near future. Please continue to monitor CMS’ website for additional information.

KEPRO, BFCC-QIO Releases Short Stay Reviews FAQ #1

KEPRO, the BFCC-QIO for Area’s 2, 3 and 4, provided a Short Stay Review webinar for key stakeholders on September 19 and 20, 2016. In October they released a pdf document titled FAQ #1: Short Stay Reviews which includes a first round portion of questions submitted during the webinars. An updated documented will be posted to their website once all remaining questions are answered.

Adjustment to the amount in controversy threshold amounts for calendar year (CY) 2017 for Medicare appeals

• Federal Register notice
• September 23, 2016
• Summary of Changes: Announcement of the annual adjustment in the adjustment to the amount in controversy (AIC) threshold amounts for ALJ hearings and judicial review under the Medicare appeals process for 2017. The CY 2017 AIC threshold amounts are $160 for ALJ hearings and $1,560 for judicial review.

 Notice of interim final rule adjusting Civil Monetary Penalties (CMP)

• Survey and certification letter
• September 8, 2016
• Summary of Changes: Announces adjustments for inflation of the CMP amounts authorized under the Social Security Act.

Partnership for Patients and the Hospital Improvement Innovation Networks: Continuing Forward Momentum on Reducing Patient Harm

• CMS Fact Sheet
• September 29, 2016
• Summary of Changes: CMS) awarded $347 million to 16 national, regional, or state hospital associations and health system organizations to serve as Hospital Improvement Innovation Networks (HIINs).

October 2016 Medicare Quarterly Provider Compliance Newsletter Released

• October 2016 Quarterly Compliance Newsletter
• Summary of Changes: Addresses Comprehensive Error Rate Testing (CERT) review of Transluminal Balloon Angioplasty, Venous; Endovenous Ablation Therapy of Incompetent Vein; Blepharoplasty; and Transurethral Resection of the Prostate and Recovery Auditor findings regarding Post-Acute Care Transfer and Skilled Nursing Facility (SNF) Coding Validation.

“Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.”

Under the two-midnight rule, hospitals may approach the decision for observation services a little differently. When a patient presents to the hospital, the first decision for the physician is, “does the patient require care in a hospital setting?” If the answer to this question is yes, then for patients with an expectation of a two-midnight stay an inpatient admission is appropriate. If the physician does not think the patient will require two midnights of care in the hospital or is unsure, then observation services are generally appropriate. When a patient who is receiving observation services approaches a second midnight in the hospital, a change to inpatient status is appropriate if the patient still requires care in a hospital setting. Considering this, it should be rare that a patient receives observation services beyond a second midnight.

Observation services are not appropriate for preparation time for outpatient testing, or for routing pre-op or post-operative services. Even with the two-midnight rule, observation services still remain a period of treatment or monitoring in order to make a decision concerning the patient’s admission or discharge.

When to Start

“Observation time begins at the clock time documented in the patient’s medical record, which coincides with the time that observation care is initiated in accordance with a physician’s order.”

What does this mean exactly? First, there must be a physician’s order for observation before observation services can begin. Observation orders cannot be back-dated. For example, when condition code 44 is used to change a patient’s status from inpatient to outpatient, observation services do not begin until there is an order for observation (which would be after the change to outpatient status). Observation services would begin at the time that order was written.

If the patient is already actively receiving care, such as in the example above, then observation begins at the time the observation order is written. For patients being transferred to a room after an observation order is written, observation care may not begin until the patient begins to receive evaluation and/or care in the hospital room.

Rounding

Observation hours are rounded to the nearest hour. This means everything from 9:01 through 9:29 is rounded to 9:00 and from 9:31 to 9:59 is rounded to 10:00. 9:30 is ambiguous and could be rounded either way. The example in the Medicare manual is a patient receiving observation services from 3:03 p.m. until 9:45 p.m. – this equals 7 hours of obs.

Concurrent Active Monitoring

“Observation services should not be billed concurrently with diagnostic or therapeutic services for which active monitoring is a part of the procedure (e.g., colonoscopy, chemotherapy).”

Medicare does not provide a list or any examples beyond the two noted in the statement above for what constitutes a procedure with “active monitoring.” This is something the hospital will have to determine, but generally includes near-constant monitoring by a nurse or other health care professional. If such a procedure occurs during a period of observation, the hospital must subtract or “carve out” that time from the total observation hours. This could be accomplished by using the beginning and ending time of the procedure, or Medicare allows hospitals to use an “average length of time” for interrupting procedures and deduct that amount of time from the observation hours.

When to End

“Observation time ends when all medically necessary services related to observation care are completed.”

Observation ending time may not coincide with the time of the physician’s discharge order. Sometimes necessary medical care may end prior to the discharge order or care may extend beyond the time of the discharge order. If after care has ended, the patient is waiting for transportation home, the waiting time should not be included in observation time.

Observation hours end when an order is written to admit the patient as an inpatient. The observation services will be bundled into the inpatient claim, but for accurate records this is when observation counting stops.

Why Bother?

Isn’t observation packaged, so why does the counting of observation hours matter? Well, yes, but no. The outpatient claim line item for observation services, billed with HCPCS code G0378, is a packaged service and receives no separate payment. However, if certain criteria are met, an observation comprehensive APC is paid for the associated visit code, such as any level ED visit, an outpatient clinic visit, or a direct referral for observation services. If 8 or more hours of observation are billed with a visit code and without a primary procedure (status indicator J1) on the claim or surgical procedure (status indicator T) on the day of or before obs, then the claim qualifies for an observation comprehensive APC payment. For 2016, the unadjusted national Medicare payment for the obs C-APC is $2174.14. Definitely worth following the rules.

Hospitals have been dealing with observation services for a long time and most providers probably have their systems down on how to accurately count and report observation services. But a reminder of the rules never hurts. 

Influenza Vaccine Payment Allowances - Annual Update for 2016-2017 Season

• Transmittal 3611, Change Request 9758, MLN Matters Article MM9758
• Issued 9/9/2016, Effective 8/1/2016, Implementation by 11/1/2016
• Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for influenza vaccines provided to Medicare beneficiaries.

Summary of Changes: Provides the availability of payment allowances for the following seasonal influenza virus vaccines.

Coding Revisions to National Coverage Determination (NCDs)

• Transmittal 1708, Change Request 9751, MLN Matters Article MM9751
• Issued 8/19/2016, Effective 1/1/2017, Implementation 1/3/2017
• Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary of Changes: The 9th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs).

October 2016 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Transmittal 3602, Change Request 9768, MLN Matters Article MM9768
• Issued 8/26/2016, Effective 10/1/2016, Implementation 10/3/2016
• Affects providers and suppliers who submit claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH&H) MACs, for services provided to Medicare beneficiaries and which are paid under the Outpatient Prospective Payment System (OPPS)..

Summary of Changes: This Recurring Update Notification describes changes to and billing instructions for various payment policies implemented in the October 2016 OPPS update.

Claim Status Category and Claim Status Codes Update

• Transmittal 3599, Change Request 9680, MLN Matters Article MM9680
• Issued 8/26/2016, Effective 1/1/2017, Implementation 1/3/2017
• Affects physicians, providers, and suppliers who submit claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, and Home Health & Hospice (HH&H) MACs for services provided to Medicare beneficiaries.

Summary of Changes: Updates, as needed, the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transactions.

Annual Clotting Factor Furnishing Fee Update 2017

• Transmittal 3607, Change Request 9759, MLN Matters Article MM9759
• Issued 8/26/2016, Effective 1/1/2017, Implementation 1/3/2017
• Affects physicians and other providers billing Medicare Administrative Contractors (MACs) for services related to the administration of clotting factors provided to Medicare beneficiaries.

Summary of Changes: This annually recurring CR announces the update to the Clotting Factor Furnishing Fee.

JW Modifier: Drug /Biological Amount Discarded/Not Administered To Any Patient - Frequently Asked Question

• Issued 8/26/2016, Effective 1/1/2017,FAQs
• Affects Providers and suppliers submitting claims for Part B drugs.

Summary of Changes: An FAQ document concerning use of the JW modifier

End of Temporary Suspension of the BFCC-QIO Short Stay Reviews

• Inpatient Hospital Reviews
• Effective 9/12/2016
• Affects acute care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities.

Summary of Changes: BFCC-QIOs will resume initial patient status reviews of short stays to determine the appropriateness of Part A payment for short stay hospital claims.

Medicare Fee for Service National Recovery Audit Program   (April 1, 2016 – June 30, 2016) Quarterly Newsletter              

• Recovery Auditor 3rd Qtr 2016 Newsletter

Summary of Changes: Overpayment and underpayment correction amounts for each RA region and the top issue per region.

Notification of Final Rule Published- Emergency Preparedness

• Survey-and-Cert-Letter-16-38
• Issued 9/8/2016, Effective 11/16/2017
• Affects Medicare and Medicaid Participating Providers and Suppliers.

Summary of Changes: The Emergency Preparedness Rule outlines the requirements for all providers and suppliers in regards to planning, preparing and training for emergency situations.

Do you sometimes feel that your life is a circus? Does this especially apply at times to your role in healthcare? The circus often includes people and animals jumping through hoops – lions, small dogs, clowns - through big hoops, small hoops, or flaming hoops. In Medicare’s clarification concerning reporting “therapy-like” services that appeared in the October 2016 OPPS Update, providers have a choice of hoops.

Before we choose a hoop, let’s consider what exactly Medicare means when they refer to “non-therapy outpatient department services that are similar to therapy services.” Rehabilitative therapy services, that is physical therapy, occupational therapy, and speech language pathology services, are provided by therapists under a plan of care in accordance with Section 1835(a)(2)(C) and Section 1835(a)(2)(D) of the Act and are paid for under Section 1834(k) of the Act. These services require functional limitation reporting and are subject to the therapy cap. Sometimes, hospital outpatients will be provided therapy-like services during the perioperative period of a Comprehensive APC (C-APC) procedure without a certified therapy plan of care. When non-therapy outpatient department services are included on the same claim as a C-APC procedure (status indicator (SI) = J1) or the specific combination of services assigned to the Observation Comprehensive APC 8011 (SI = J2), these services are considered adjunctive to the primary procedure and their payment is included as a packaged part of the payment for the C-APC procedure.

Hoop One

In the July 2016 OPPS Update, CMS put forth a requirement to be effective July 1, 2016, for these non-therapy outpatient department services adjunctive to a C-APC to be reported without HCPCS codes and with revenue code 0940. In comments on the June 8, 2016 Hospital Open Door Forum, CMS stated this change in reporting requirements was due to provider concerns about having to report functional limitation G codes and modifiers with these packaged “therapy-like” services. Provider response to CMS’s explanation was that this solution simply created different problems from the one it solved. Shortly after, CMS delayed the implementation of the reporting change for therapy-like services until October 1, 2016. The October OPPS update gives provider two options for claims received on and after October 1, 2016 for dates of services on and after January 1, 2015. One option continues to be reporting these “non-therapy” therapy services with revenue code 0940 and no HCPCS codes. Hopefully CMS has made modifications to claim processing systems to allow the reporting of revenue code 0940 without HCPCS codes, since this revenue code historically has required the presence of HCPCS codes.

Hoop Two

The second option in the October update for reporting “therapy-like” services adjunctive to C-APCs is that providers can continue to report these with the therapy revenue codes (042x, 043x, and 044x) and with therapy HCPCS/CPT codes. However, if a provider chooses this option, they must follow all the requirements of rehabilitative therapy code reporting, including occurrence codes, therapy modifiers, and the reporting of functional limitation G codes and modifiers. The therapy cap will not be affected since payment for these services is packaged into the comprehensive APC payment.

So do you want to jump through the hoop into the lion’s mouth or the flaming hoop? Your choice, but neither one is without its complications.

The phrase “waste not, want not” means to use one’s resources wisely in order to always have plenty and avoid poverty. Although Medicare pays for drug wastage in certain circumstances, they also expect healthcare providers and suppliers to “use drugs or biologicals most efficiently, in a clinically appropriate manner.” But when waste cannot be avoided, starting next year, CMS is requiring reporting that will allow them to identify and monitor billing and payment for discarded drugs under Medicare Part B.

As promised, CMS has released a list of frequently asked questions concerning the use of the JW modifier. The JW modifier indicates that a portion of a drug or biological was discarded or wasted. Currently the use of the JW modifier is at the discretion of the jurisdictional Medicare Administrative Contractors (MACs). For example, Cahaba GBA, MAC for Jurisdiction JJ (Alabama, Georgia, and Tennessee) does not require the reporting of the JW modifier for wasted drugs/biological. In order to be more consistent and better able to track drug wastage, CMS is requiring the use of the JW modifier nationally effective January 1, 2017, in order for providers/suppliers to seek payment for drug/biological wastage.

The JW modifier is to be used on Part B drug claims for discarded drugs and biologicals (hereafter referred to as drugs) when they are in single-use vials or packaging. If uncertain, the information as to whether a drug or biological is single use can be found in the manufacturer’s packaging insert. The discarded drug amount is the amount of a single use vial or other single use package that remains after administering a dose/quantity of the drug to a Medicare patient. Multiple use vials/packaging are not eligible for Medicare payment for discarded amounts.

The JW modifier will mainly be used for reporting drug wastage in physician offices and hospital outpatient departments (including Critical Access Hospitals (CAHs)). Some suppliers such as pharmacies may need to report the JW modifier, but it is unlikely they will have much, if any, drug wastage. Hospital Part B inpatient claims on a 12X type of bill would also report the JW modifier for separately payable drugs. Eligible and participating 340B providers are not exempt from use of the JW modifier.

One of the main things to remember about the use of the JW modifier is that it only applies to drugs that are separately payable, for example drugs with an OPPS status indicator of G (pass-through drugs) and K (separately payable non-pass-through drugs). In the outpatient hospital setting, this applies to separately payable drugs billed for surgical patients, patients in the emergency room, patients in outpatient clinics, and other outpatients receiving separately payable drugs.

This means that drugs that are not separately paid by Medicare do not require the use of the JW modifier. For example:

• Drugs provided in rural health clinics (RHCs) and federally qualified health centers (FQHCs) since these are not separately paid,
• Drugs provided during hospital inpatient admissions (Part A) that are paid under the Inpatient Prospective Payment System (IPPS),
• Drugs given to an outpatient but combined to an inpatient Part A claim under the 3 day payment window rule,
• Packaged drugs, such as drugs with an OPPS status indicator of “N” or an SI of “K” that are bundled with comprehensive APCs (see OPPS Addendum D1 for explanation of services packaged with comprehensive APCs)
• Overfill wastage (CMS has made it clear in the past that overfill, which is any amount of drug greater than the amount identified on the package, is not billable.)

CMS also exempts drugs paid under the Part B drug Competitive Acquisition Program (CAP) although at this time the CAP remains on hold so there is no current list of CAP medications.)

One of the questions not clearly addressed by the FAQs is whether providers and suppliers are required to report drug wastage or can they elect to absorb the cost of discarded drugs. The guidance states that the JW modifier is used in order to obtain payment for the discarded amount of a drug or biological and is not needed if no discarded drug is being billed to the payer. So IF you are going to bill and expect payment for drug wastage, you must use the JW modifier January 1, 2017 and after.

In using the JW modifier on and after January 2017, providers must report the amount of the discarded drug on a separate claim line with the JW modifier. The unit field should reflect the quantity of drug discarded. If the provider is unable to quantify the amount of drug wasted, the JW modifier is not required. Do not report one claim line with combined units for amount of drug administered and wasted. Also realize if the amount of drug administered or the amount of drug wasted is less than the amount described by one HCPCS billing unit, then it is not necessary to use the JW modifier.

Prior to January 1, 2017, providers must follow the directions of their MACs or they may voluntarily report the JW modifier. Providers should check their MACs websites for any specific direction concerning the reporting of the JW modifier prior to the mandatory January 1, 2017 requirement. For example, here is some guidance from a few MACs and you can see that current instructions differ from MAC to MAC – that is why it is important to determine your MAC’s guidance for use of the JW modifier in 2016.

Cahaba GBA - Cahaba DOES NOT require the use of the JW modifier at this time. If providers wish to designate that a portion of a single dose vial is being discarded, please continue to bill the injection on ONE line and add the JW modifier to the procedure code and document the discarded amount in the patents records. Bill for the complete vial, even though part of the vial is being discarded. DO NOT split the billing to two claim lines: one with the JW and one without.

First Coast - For billing purposes, First Coast does not require the use of modifier JW prior to January 1, 2017. Drug wastage is billed by combining on a single line the wastage and administered dosage amount.

NGS - National Government Services does NOT require the use of the JW modifier at this time but providers may choose to use it. Claims will process appropriately with or without the JW modifier. If the JW modifier is used; it should be appended to a separate line for the HCPCS code (separate from the amount administered) indicating the amount (in units) discarded.

One thing CMS and all the MACs agree on is that wastage of the drug must be documented in the patient’s medical record to support the billing of discarded drugs. Here is CMS’s answer to the FAQ concerning documentation of drug wastage:

“CMS expects that providers and suppliers will maintain accurate (medical and/or dispensing) records for all beneficiaries as well as accurate purchasing and inventory records for all drugs that were purchased and billed to Medicare. General guidance on documentation is available in MLN Matters SE 1316. Providers and suppliers should also check with the MAC that processes their Part B drug claims in case additional information on billing and documentation is available at the local level.”

For complete details concerning the JW modifier, see the following CMS guidance:

• MLN Matters Article MM9603,
• Section 40 of Chapter 17 of the Medicare Claims Processing Manual,
• CMS’s FAQ document
• Any information on the JW modifier on your local MAC’s website

Providers should use drugs wisely and efficiently, but if wastage cannot be avoided and the provider wants to be paid for it, then understanding the proper use, reporting and documentation for the JW modifier is critical.

TRANSMITTALS

October 2016 Integrated Outpatient Code Editor (I/OCE) Specifications Version 17.3

• Transmittal 3591, Change Request 9754, MLN Matters Article MM9754
• Issued 8-12-16, Effective 10-1-16, Implementation 10-3-16
• Affects providers who submit claims to Medicare Administrative Contractors MACs), including Home Health and Hospices (HH+H) MACs, for services provided to Medicare beneficiaries.

Summary of Changes: Quarterly update of the I/OCE. All institutional outpatient claims (which includes non-OPPS hospital claims) are routed through a single integrated OCE to apply claims processing edits.

Medicare Part B Clinical Laboratory Fee Schedule: Guidance to Laboratories for Collecting and Reporting Data for the Private Payor Rate-Based Payment System

• MLN Matters Article SE1619
• Issued 8-8-16
• Affects Medicare Part B clinical laboratories who submit claims to Medicare Administrative Contractors (MACs) for services furnished to Medicare beneficiaries.

Summary of Changes: This guidance includes clarifications for determining whether a laboratory meets the requirements to be an “applicable laboratory,” the applicable information (that is, private payor rate data) that must be collected and reported to the Centers for Medicare & Medicaid Services (CMS), the entity responsible for reporting applicable information to CMS, the data collection and reporting periods, and the schedule for implementing the new CLFS

Coding Revisions to National Coverage Determination (NCDs)

• Transmittal 1708, Change Request 9751, Transmittal 1708
• Issued 8-19-16, Effective 1-1-17 unless otherwise noted, Implementation 1-3-17

Summary of Changes: The 9th quarterly maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs)

OTHER UPDATES

2017 ICD-10-CM and ICD-10-PCS 2017 Guidelines

• ICD-10-CM Guidelines are available on the CDC and CMS Websites http://www.cdc.gov/nchs/icd/icd10cm.htm and https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html
• ICD-10-PCS Guidelines on CMS Website https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-PCS-and-GEMs.html

Summary of Changes: To easily identify what is new for the October 1, 2016 start date for the CMS 2017 Fiscal Year, narrative changes appear in bold text. The ICD-10-CM Preface for 2017 found on the CDC website indicates that “ICD-10-CM is the United States’ clinical modification of the World Health Organization’s ICD-10. The term “clinical” is used to emphasize the modification’s intent: to serve as a useful tool in the area of classification of morbidity data for indexing of health records, medical care review, and ambulatory and other health care programs, as well as for basic health statistics. To describe the clinical picture of the patient the codes must be more precise than those needed only for statistical groupings and trend analysis.”

Updates to the Clarifying Questions and Answers Related to the July 6, 2015, CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities for Physicians

• Questions & Answers pdf
• Released August 18, 2016

Summary of Changes: The ICD-1 flexibilities are set to expire October 1, 2016. Providers should already be coding to the highest level of specificity. The flexibilities were “solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of fraud.”

TRANSMITTALS

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update

• Transmittal 3562, Change Request 9695, MLN Matters Article MM9695
• Issued July15, 2016, Effective October 1, 2016, Implementation October 3, 2016
• Affects physicians, 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 update the Remittance Advice Remark Code (RARC) and Claim Adjustment Reason Code (CARC) lists and also to instruct ViPS Medicare System (VMS) and Fiscal Intermediary Shared System (FISS) to update Medicare Remit Easy Print (MREP) and PC Print.

The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year 2014 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long Term Care Hospitals (LTCH)

• Transmittal 1681, Change Request 9648, MLN Matters Article MM9648
• Issued July 15, 2016, Effective August 16, 2016, Implementation August 16, 2016
• Affects Inpatient Prospective Payment System (IPPS) hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long Term Care Hospitals (LTCHs) submitting
• claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary of Changes: Provides updated data for determining the disproportionate share adjustment for IPPS hospitals and the Low Income Patient (LIP) adjustment for IRFs as well as payments as applicable for LTCH discharges

Quarterly Update to the Correct Coding Initiative (CCI) Edits, Version 22.3, Effective October 1, 2016

• Transmittal 3561, Change Request 9725, MLN Matters Article MM9725
• Issued July 15, 2016, Effective October 1, 2016, Implementation October 3, 2016
• Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary of Changes: This is the normal update to the CCI procedure to procedure edits.

July 2016 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Transmittal 3552 and 3557, Change Request 9658, MLN Matters Article MM9658
• Issued June 28 and July 1, 2016, Effective July 1, 2016, Implementation July 5, 2016
• Affects providers and suppliers who submit claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH&H) MACs, for services provided to Medicare beneficiaries and which are paid under the Outpatient Prospective Payment System (OPPS).

Summary of Changes: This Recurring Update Notification describes changes to and billing instructions for various payment policies implemented in the July 2016 OPPS update. Transmittal 3557 replaces Transmittal 3552 to include the statement announcing delay in implementation of the reporting for certain outpatient department services (that are similar to therapy services) (“non-therapy outpatient department services”) that are adjunctive to comprehensive APC procedures.

Medicare Coverage of Diagnostic Testing for Zika Virus

• MLN Matters Article SE1615
• Issued June 27, 2016
• Affects physicians, providers, and clinical diagnostic laboratories who submit claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

Summary of Changes: This MLN Matters Special Edition Article informs the public that Medicare covers Zika virus testing under Medicare Part B as long as the clinical diagnostic laboratory test is reasonable and necessary for the diagnosis or treatment of a person’s illness or injury. This article reminds laboratories furnishing Zika virus tests to contact their MACs for guidance on the appropriate billing codes to use on claims for Zika virus testing. Furthermore, laboratories should provide resources and cost information as may be requested by the MACs in order for the MACs to establish appropriate payment amounts for the tests.

Notice of New Interest Rate for Medicare Overpayments and Underpayments -4th Qtr Notification for FY 2016

• Transmittal 270, Change Request 9750
• Issued July 12, 2016, Effective July 18, 2016, Implementation July 18, 2016

Summary of Changes: Recurring notification of interest rates.

OTHER UPDATES

CMS Proposes Hospital Outpatient Prospective Payment System Changes to Better Support Physicians and Improve Patient Care

• 2017 OPPS Proposed Rule CMS-1656-P
• Issued July 6, 2016

Summary of Changes: This proposed rule would revise the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2017 to implement applicable statutory requirements and changes arising from our continuing experience with these systems.

Medicare Quarterly Compliance Newsletter

• July 2016 Edition

Summary: Articles on Automatic External Defibrillators, Treprostinil Inhalation Solution, Therapeutic Shoes for Persons with Diabetes, and Hospital Outpatient Dental Services.

Growing up in the south, I remember being told that summer is mosquito season. What I found in writing this article is that it’s more about the temperature levels. Specifically, when temperatures reach a consistent 50°F mosquito eggs begin hatching and mosquito season begins. So, in more temperate parts of the nation, mosquitoes can be present year-round. Here in my home state of Alabama the mosquito season typically begins in early March.

I also learned that there are over 3,000 different species of mosquitoes throughout the world; currently 176 of these species has been recognized in the United States. Today, we are focusing on just one group of mosquito, Aedes mosquitoes that can transmit the Zika virus.

About the Virus

The Zika Virus was first discovered in 1947 in the Zika Forest of Uganda. The first human cases of the virus were detected in 1952 and since outbreaks have been reported in tropical Africa, Southeast Asia, and the Pacific Islands. The disease is transmitted by Aedes mosquitoes who also transmit three other vector-borne diseases (dengue, chikungunya and yellow fever).

The Centers for Disease Control (CDC) indicates that most infected people are asymptomatic. When a person is symptomatic, common symptoms of the virus normally lasts for 2-7 days and can include:

• Acute onset of fever,
• Maculopapular rash,
• Headache,
• Muscle and joint pain, and
• Conjunctivitis.

The World Health Organization (WHO) notes two serious complications reported by Brazil:

• July 2015: Brazil reported an association between the virus and Guillain-Barre syndrome.
• October 2015: Brazil reported an association between the virus infection and microcephaly.

On February 1, 2016 the WHO declared the Zika virus a Public Health Emergency of International Concern (PHEIC) and since then has been posting weekly Zika Situation Reports. The last report posted at the time of this article was June 23, 2016. Key notes of concern from the June 23rd Summary includes:

• As of June 22, 2016, 61 countries and territories report continuing mosquito-borne transmissions of which:
• 47 countries are experiencing a first outbreak of the virus since 2015 with ongoing transmissions by mosquitoes.
• Ten countries have reported evidence of person-to-person transmission of the virus noted to probably be via a sexual route.
• As of June 22, 2016, microcephaly and other central nervous system (CNS) malformations potentially associated with the virus or suggestive of congenital infection have been reported by twelve countries or territories.
• As of June 9th, the CDC has reported three live born infants with birth defects and three pregnancy losses with birth defects with laboratory evidence of possible Zika virus infection.
• 13 Countries and territories worldwide have reported an increase incidence of Guillain-Barre syndrome (GBS) and/or laboratory confirmation of a Zika virus infection among GBS cases.

Medicare to Cover Diagnostic Testing for Zika Virus

CMS has released MLN Matters Article SE1615 titled Medicare Coverage of Diagnostic Testing for Zika Virus. Specific Provider Action Needed includes:

• Informing the public that Medicare covers testing under Medicare Part B “as long as the clinical diagnostic laboratory test is reasonable and necessary for the diagnosis or treatment of a person’s illness or injury,”
• As currently there are no HCPCS codes for testing of the Zika virus, laboratories furnishing the Zika tests should contact their Medicare Administrative Contractors (MACs) for guidance on appropriate billing codes to use on the claims; and
• Labs should provide “resources and cost information as may be requested by the MACs in order for the MACs to establish appropriate payment amounts for the tests.”

ICD-10-CM Coding for Zika

The Zika Virus was discussed during the March 9-10, 2016 ICD-10 Coordination and Maintenance Committee Meeting. ICD-10-CM currently classifies the virus to code A92.8, Other specific mosquito-borne virus.

In December 2015 the WHO noted the need for a separate code for the Zika Virus to allow for tracking of cases. The WHO proposed a new code for the Zika virus (A92.5). To be consistent with the planned WHO ICD-10 update, effective October 1, 2016 ICD-10-CM will include the addition of the following:

Chapter 1 – Certain Infectious and Parasitic Diseases (A00-B99)

A92 – Other Mosquito-borne viral fevers

New Code: A92.5 – Zika virus disease
Zika virus fever
Zika virus infection
Zika, NOS

Prevention

The American Mosquito Control Association (AMCA) is an association “dedicated to providing leadership, information and education leading to the enhancement of public health and quality of life through the suppression of mosquitoes.” In fact, this past week of June 26 – July 2nd was National Mosquito Control Awareness Week 2016. In a Press Release template, the AMCA® reminds the public to practice the THREE D's of Mosquito Prevention and Protection:

• Drain: Empty out water containers at least once per week
• Dress: Wear long sleeves, long pants, and light-colored, loose-fitting clothing, and
• Defend: Properly apply an approved repellant such as DEET, picaridin, IR3535 or oil of lemon-eucalyptus.

TRANSMITTALS

Recovering Overpayments from Providers Who Share Tax Identification Numbers

• MLN Matters Article SE1612
• Issued June 22, 2016
• Affects providers of services and suppliers who share the same Tax Identification Number (TIN) even though they may have different National Provider Identifiers or other billing numbers used to bill Medicare.

Summary of Changes: Allows CMS to recover payments made to a provider of services or supplier that shares the same TIN with a provider of services or supplier that has an outstanding Medicare overpayment across multiple states within a Medicare Administrative Contractor (MAC) jurisdiction

October Quarterly Update to 2016 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement

• Transmittal 3546, Change Request 9688, MLN Matters Article MM9688
• Issued June 17, 2016, Effective October 1, 2016, Implementation October 3, 2016
• Affects physicians, providers, and suppliers submitting claims to all Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries who are in a Part A Skilled Nursing Facility (SNF) stay.

Summary of Changes: This notification provides updates to the lists of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the consolidated billing provision of the SNF Prospective Payment System (PPS)

JW Modifier: Drug Amount Discarded/Not Administered to any Patient

• Transmittal 3538, Change Request 9603, MLN Matters Article MM9603
• Issued June 9, 2016, Effective January 1, 2017, Implementation January 3, 2017
• Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for drugs or biologicals administered to Medicare beneficiaries.

Summary of Changes: Transmittal 3530, dated May 24, 2016, is being rescinded and replaced by Transmittal 3538 to update the Effective and Implementation dates. Effective January 1, 2017, claims for discarded drug or biological amount not administered to any patient, shall be submitted using the JW modifier. Also, effective January 1, 2017, 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.

Claim Status Category and Claim Status Codes Update

• Transmittal 3527, Change Request 9550, MLN Matters Article MM9550
• Issued May 20, 2016, Effective October 1, 2016, Implementation 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 update as needed the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transactions. This Recurring Update Notification (RUN) can be found in Chapter 31, Section 20.7.

July 2016 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Transmittal 3523, Change Request 9658, MLN Matters Article MM 9658
• Issued May 13, 2016, Effective July 1, 2016, Implementation July 5, 2016
• Affects providers and suppliers who submit claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH&H) MACs, for services provided to Medicare beneficiaries and which are paid under the Outpatient Prospective Payment System (OPPS).

Summary of Changes: This Recurring Update Notification describes changes to and billing instructions for various payment policies implemented in the July 2016 OPPS update.

July 2016 Integrated Outpatient Code Editor (I/OCE) Specifications Version 17.2

• Transmittal 3524, Change Request 9661,MLN Matters Article MM9661
• Issued May 13, 2016, Effective July 1, 2016, Implementation July 5, 2016
• Affects providers submitting claims to Medicare Administrative Contractors (MACs) for outpatient services provided to Medicare beneficiaries and paid under the Outpatient Prospective Payment System (OPPS) and for outpatient claims from any non-OPPS provider not paid under the OPPS. It is also intended for claims for limited services when provided in a Home Health Agency (HHA) not under the Home Health PPS (HH PPS) or claims for services to a hospice patient for the treatment of a non-terminal illness..

Summary of Changes: This notification provides the Integrated OCE instructions and specifications for the Integrated OCE that will be utilized under the OPPS and Non-OPPS for hospital outpatient departments, community mental health centers, all non-OPPS providers, and for limited services when provided in a home health agency not under the Home Health Prospective Payment System or to a hospice patient for the treatment of a non-terminal illness. The attached Recurring Update Notification applies to 100-04, Chapter 4, section 40.1

OTHER NEWS

Temporary Pause of QIO Short Stay Reviews

• Inpatient Hospital Reviews Webpage
• Updated June 6, 2016

Summary of Changes: CMS requires that beginning June 6, 2016, the BFCC-QIOs re-review all short stay patient status claims that were denied under the QIO medical review process.

Medicare Will Use Private Payor Prices to Set Payment Rates for Clinical Diagnostic Laboratory Tests Starting in 2018

• CLFS Payment Rates Press Release
• Issued June 17, 2016
• Affects laboratories performing clinical diagnostic laboratory tests

Summary of Changes: CMS released a final rule implementing Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA), requiring laboratories performing clinical diagnostic laboratory tests to report the amounts paid by private insurers for laboratory tests. Medicare will use these private insurer rates to calculate Medicare payment rates for laboratory tests paid under the Clinical Laboratory Fee Schedule (CLFS) beginning January 1, 2018. Further details of this rule can be found by clicking here.

CMS Proposes Rule to Improve Health Equity and Care Quality in Hospitals

• https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-06-13.html
• Issued June 13, 2016
• Affects the 6,228 hospitals and critical access hospitals that participate in Medicare or Medicaid.

Summary of Changes: The rule proposes to reduce overuse of antibiotics and implement comprehensive requirements for infection prevention. The proposed rule also advances protections for traditionally underserved and often excluded populations based on race, color, religion, national origin, sex (including gender identity), age, disability, or sexual orientation. For a closer look at this proposed rule, click here.

Medicare Makes Enhancements to the Shared Savings Program to Strengthen Incentives for Quality Care

• https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-06-06.html
• Issued June 6, 2016
• Affects Accountable Care Organizations in the Medicare Shared Savings Program.

Summary of Changes: CMS released a final rule improving how Medicare pays Accountable Care Organizations in the Medicare Shared Savings Program for delivering better patient care. Medicare is moving away from paying for each service a physician provides towards a system that rewards physicians for coordinating with each other. Accountable Care Organizations are a major part of that transition, rewarding providers that deliver high-quality, efficient, and coordinated care for patients.

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