Knowledge Base Category -
The federal government has penalized 764 hospitals — including more than three dozen it simultaneously rates as among the best in the country — for having the highest numbers of patient infections and potentially avoidable complications.
The penalties — a 1% reduction in Medicare payments over 12 months — are based on the experiences of Medicare patients discharged from the hospital between July 2018 and the end of 2019, before the pandemic began in earnest. The punishments, which the Affordable Care Act requires be assessed on the worst-performing 25% of general hospitals each year, are intended to make hospitals focus on reducing bedsores, hip fractures, blood clots, and the cohort of infections that before covid-19 were the biggest scourges in hospitals. Those include surgical infections, urinary tract infections from catheters, and antibiotic-resistant germs like MRSA.
This year’s list of penalized hospitals includes Cedars-Sinai Medical Center in Los Angeles; Northwestern Memorial Hospital in Chicago; a Cleveland Clinic hospital in Avon, Ohio; a Mayo Clinic hospital in Red Wing, Minnesota; and a Mayo hospital in Phoenix. Paradoxically, all those hospitals have five stars, the best rating, on Medicare’s Care Compare website.
Eight years into the Hospital-Acquired Condition Reduction Program, 2,046 hospitals have been penalized at least once, a KHN analysis shows. But researchers have found little evidence that the penalties are getting hospitals to improve their efforts to avert bedsores, falls, infections, and other accidents.
“Unfortunately, pretty much in every regard, the program has been a failure,” said Andrew Ryan, a professor of health care management at the University of Michigan’s School of Public Health, who has published extensively on the program.
“It’s very hard to capture patient safety with the surveillance methods we currently have,” he said. One problem, he added, is “you’re kind of asking hospitals to call out events that are going to have them lose money, so the incentives are really messed up for hospitals to fully disclose” patient injuries. Academic medical centers say the reason nearly half of them are penalized each year is that they are more diligent in finding and reporting infections.
Another issue raised by researchers and the hospital industry is that under the law, the Centers for Medicare & Medicaid Services each year must punish the quarter of general care hospitals with the highest rates of patient safety issues even if they have improved and even if their infection and complication rates are only infinitesimally different from those of some non-penalized hospitals.
In a statement, CMS noted it had limited ability to alter the program. “CMS is committed to ensuring safety and quality of care for hospital patients through a variety of initiatives,” CMS said. “Much of how the Hospital-Acquired Condition (HAC) Reduction Program is structured, including penalty amounts, is determined by law.”
In allotting the penalties, CMS evaluated 3,124 general acute hospitals. Exempted from the evaluation are around 2,000 hospitals. Many of those are critical access hospitals, which are the only hospitals serving a geographic — often rural — area. The law also excuses hospitals that focus on rehabilitation, long-term care, children, psychiatry, or veterans. And Maryland hospitals are excluded because the state has a different method for paying its hospitals for Medicare patients.
For the penalized hospitals, Medicare payments are reduced by 1% for each bill from October 2021 through September 2022. The total amount of the penalties is determined by how much each hospital bills Medicare.
A third of the hospitals penalized in the list released this year had not been punished in the previous year. Some, like UC Davis Medical Center in California, have gone in and out of the penalty box over the program’s eight years. Davis has been penalized four years and not punished four years.
“UC Davis Medical Center is usually within a few points of the [Hospital-Acquired Condition Reduction Program] threshold, so it’s not unusual to move in and out of the program year to year,” UC Davis Health said in an email. It said Davis ranked 38th out of 101 academic medical centers that use a private quality measurement system.
The Cleveland Clinic said that its satellite hospital in Avon has received awards from private groups, such as an “A” grade for patient safety from the nonprofit Leapfrog Group. Both it and Cedars-Sinai touted their five-star ratings. In addition, Cedars said that overall assessment comes even though the hospital deals with large numbers of very sick patients. “This [star] rating is particularly meaningful because of the complexity of the care that many of our patients require,” Cedars said in a statement.
Other hospitals declined to comment or did not respond to emails.
The KHN analysis found that the government penalized 38 of the 404 hospitals that were both included in the hospital-acquired conditions evaluation and had received five stars for “overall quality,” which CMS calculates using dozens of metrics. Those include not just infection and complication rates but also death rates, readmission frequencies, ratings that patients give the hospital after discharge, and hospitals’ consistency in following basic protocols in a timely manner, such as giving patients medicine to break up blood clots in the 30 minutes after they display symptoms of potential heart attacks.
In addition, 138 of 814 hospitals with the next-highest rating of four stars were docked by the program, KHN found.
Lower-rated hospitals were penalized with a higher frequency: Although just 9% of five-star hospitals were punished, 67% of one-star hospitals were.
KHN’s analysis found major discrepancies between the list of penalized hospitals and how Medicare’s Care Compare rated them for virtually the same patient safety infection rates and conditions. On the Medicare site, two-thirds of the penalized hospitals are rated as “no different than average” or “better than average” for the public safety measures CMS uses in assigning star ratings. The major differences center on the time frames for those measures and the structure of the penalty program. The Medicare website, for instance, evaluated only one year of infection rates, rather than the 18 months’ worth that the penalty program examined. And the public ratings are more forgiving than the penalties: Care Compare rates each hospital’s patient safety metric as average unless it’s significantly higher or lower than the scores of most hospitals, while the penalty program always punishes the lowest quartile.
Nancy Foster, the vice president for quality and patient safety at the American Hospital Association, said the penalties would cause more stress to hospitals already struggling to handle the influx of covid patients, staffing shortages, and the extra costs of personal protective equipment. “It is demoralizing to the staff when they see their hospital is deemed unsafe or less safe than other hospitals,” she said.
Dr. Karen Joynt Maddox, co-director of the Center for Health Economics and Policy at Washington University in St. Louis, said it was time for Congress and CMS to reevaluate the penalty program. “When this program had started, the thought was that we would get to zero” avoidable complications, she said, “and that hasn’t proven to be the case despite a really good effort on the part of some of these hospitals.”
She said the hospital-acquired conditions penalty program, along with other quality-improvement programs created by the ACA, feels “very ready for a refresh.”
Subscribe to KHN's free Morning Briefing.
MEDICARE MLN ARTICLES & TRANSMITTALS – RECURRING UPDATES
April 2021 Integrated Outpatient Code Editor (I/OCE) Specifications Version 22.1
- Article Release Date: March 8, 2021
- What You Need to Know: Included in this MLN article are changes to the April 2021 version of the I/OCE instructions and specifications for the I/OCE that Medicare uses under the OPPS and non-OPPS for hospital outpatient departments, community mental health centers, all non-OPPS providers, limited services when provided in a home health agency not under the HH PPS, and for a hospice patient for treating a non-terminal illness.
- MLN MM12187: https://www.cms.gov/files/document/mm12187.pdf
Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens
- Article Release Date: March 9, 2021
- What You Need to Know: Changes to CY 2021 travel allowances bill per mileage basis (HCPCS P9603) and on a flat rate basis (HCPCS P9604) are included in this article. Note, “Medicare Part B allows payment for a specimen collection fee and travel allowance, when medically necessary, for a laboratory technician to draw a specimen from either a nursing home patient or homebound patient under Section 1833(h)(3) of the Act. Payment for these services is made based on the Clinical Laboratory Fee Schedule (CLFS).”
- MLN MM12140: https://www.cms.gov/files/document/mm12140.pdf
April 2021 Update to the Fiscal Year (FY) 2021 Inpatient Prospective Payment System
- Article Release Date: March 9, 2021
- What You Need to Know: This MLN Article provides notice of changes that CMS is making for the April 2021 update of the FY 2021 Inpatient Prospective Payment System (IPPS). CMS notes that MACs will be reprocessing certain claims as explained in this article.
- MLN MM12062: https://www.cms.gov/files/document/mm12062.pdf
April 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- Article Release Date: March 8, 2021
- What You Need to Know: Related CR 12175 describes changes to and billing instructions for various payment policies implemented in the April 2021 Outpatient Prospective Payment System (OPPS) update. The April 2021 Integrated Outpatient Code Editor (I/OCE) will reflect the HCPCS, Ambulatory Payment Classification (APC), HCPCS Modifier, and Revenue Code additions, changes, and deletions identified in CR 12175.
- MLN MM 12175: https://www.cms.gov/files/document/mm12175.pdf
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
- Article Release Date: March 10, 2021
- What You Need to Know: Quarterly updates to the Clinical Laboratory Fee Schedule (CLFS) are detailed in this MLN article, including a table of new codes effective April 1, 2021.
- MLN Article MM12178: https://www.cms.gov/files/document/mm12178.pdf
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – April 2021 Update
- Article Release Date: March 10, 2021
- What You Need to Know: This MLN article provides highlights from Change Request (CR) 12155 which includes April 2021 updates to the 2021 MPFS. CMS notes in the article that “MACs won’t search their files to either retract payment for claims already paid or to retroactively pay claims. However, MACs will adjust claims that you bring to their attention.”
- MLN MM12155: https://www.cms.gov/files/document/mm12155.pdf
One-Time Transmittal 10599 (Change Request 12089): HIPAA Electronic Data Interchange (EDI) Front End Updates for July 2021
- Transmittal Release Date: March 11, 2021
- What You Need to Know: The purpose of this Change Request (CR) is to provide the July 2021 Combined Common Edits/Enhancements Module (CCEM) edits for the Part A and Part B Medicare Administrative Contractors (A/B MACs) and the Common Electronic Data Interchange (CEDI) contractor. Additionally, this CR directs Shared Systems to appropriately update the CCEM.
- Change Request 12089: https://www.cms.gov/files/document/r10599otn.pdf
April Quarterly Update for 2021 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
- Article Release Date: March 12, 2021
- What You Need to Know: This article details changes in the DMEPOS fee schedules that Medicare updates on a quarterly basis.
- MLN MM12193: https://www.cms.gov/files/document/mm12193.pdf
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) & PC Print Update
- Article Release Date: March 12, 2021
- What You Need to Know: This article details updates to the RARC and CARC lists and instructs Medicare’s Shared System Maintainers (SSMs) to update MREP and PC Print.
- MLN MM12102: https://www.cms.gov/files/document/mm12102.pdf
Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2021
- Article Release Date: March 17, 2021
- What You Need to Know: Included in this article are the Calendar Year 2021 rate updates and policies for the ESRD PPS. Of note, the January 2021 ESRD PRICER did not apply the network reduction to Intermittent Peritoneal Dialysis (IPD) revenue code 0831 and ultrafiltration revenue code 0881 in error. The revised PRICER is correcting this error.
- MLN MM12188: https://www.cms.gov/files/document/mm12188.pdf
April 2021 Quarterly Update to HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement
- Article Release Date: March 25, 2021
- What You Need to Know: Updates to lists of HCPCS codes subject to the consolidated billing provision of the SNF Prospective Payment System (PPS) are provided in this MLN article.
- MLN MM12212: https://www.cms.gov/files/document/mm12212.pdf
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2021
- Article Release Date: March 23, 2021
- What You Need to Know: This article and related Change Request (CR) 12171 announced changes in the July 2021 quarterly release of the edit module for clinical diagnostic laboratory services.
- MLN MM12171: https://www.cms.gov/files/document/mm12171.pdf
OTHER MEDICARE MLN ARTICLES & TRANSMITTALS
Updated Billing Requirements for Home Infusion Therapy (HIT) Services on or after January 1, 2021
- Article Release Date: March 15, 2021
- What You Need to Know: Following is an excerpt from this article regarding new changes to Medicare claims processing for HIT services on or after January 1, 2021:
- “As described in the 21st Century Cures Act, Medicare will make a separate payment for HIT services under the permanent HIT benefit to qualified home infusion suppliers, effective January 1, 2021. Home infusion drugs are assigned to three payment categories, as determined by the HCPCS J-code:
- Payment Category 1: Includes certain intravenous antifungals and antivirals, uninterrupted long-term infusions, pain management, inotropic, and chelation drugs
- Payment Category 2: Includes subcutaneous immunotherapy and other certain subcutaneous infusion drugs
- Payment Category 3: Includes certain chemotherapy drugs. MLN Matters article MM11880 lists the home infusion therapy service G-codes and corresponding home infusion therapy drug J-codes.
- MLN MM12108: https://www.cms.gov/files/document/mm12108.pdf
Common Working File (CWF) Edits for Medicare Telehealth Services and Manual Update
- Article Release Date: March 18, 2021
- What You Need to Know: This article is for physicians, non-physician practitioners, nursing facilities, and other providers submitting telehealth claims to MACs for nursing facility services.
- MLN MM12068: https://www.cms.gov/files/document/mm12068.pdf
Update to Rural Health Clinic (RHC) Payment Limits
- Article Release Date: March 16, 2021
- What You Need to Know: This article provides information about the payment limits for RHCs effective April 1, 2021.
- MLN MM12185: https://www.cms.gov/files/document/mm12185.pdf
Update to the Manual for Telephone Services, Physician Assistant (PA) Supervision, and Medical Record Documentation for Part B Services
- Article Release Date: March 24, 2021
- What You Need to Know: This article serves as notice regarding updates made to Chapter 15 of the Medicare Benefit Policy Manual for Physician Supervision for Physician Assistant (PA) Services and Medical Record Documentation for Part B services.
- MLN MM11862: https://www.cms.gov/files/document/mm11862.pdf
New Provider Enrollment Administrative Action Authorities
- Article Release Date: March 24, 2021
- What You Need to Know: This Special Edition MLN article provides information about the CMS Final Rule titled Program Integrity Enhancement to the Provider Enrollment Process. This Final Rule was issued on September 10, 2019. Included in this MLN article is the following note, “In light of the pandemic and various other factors, we will not begin updating the Form CMS-855 applications with affiliation disclosure for at least another 12 months.”
- MLN SE21003: https://www.cms.gov/files/document/se21003.pdf
REVISED MEDICARE MLN ARTICLES & TRANSMITTALS
Fiscal Year (FY) 2021 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Changes
- Article Release Date: September 22, 2020 – Revised March 9, 2021
- What You Need to Know: In CR 11879, CMS changes the 25th percentile wage index value from 0.8465 to 0.8649. This MLN article reflects this change.
- MLN MM11879: https://www.cms.gov/files/document/mm11879.pdf
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits
- Article Release Date: February 23, 2021 – Revised March 9, 2021
- What You Need to Know: This MLN article was revised to reflect the revised CR 12131, which changed the date CMS added HCPCS code 87428 to the correct date of November 10, 2020.
- MLN MM12131: https://www.cms.gov/files/document/mm12131.pdf
MEDICARE COVERAGE UPDATES
OIG Reports and Guidance regarding Polysomnography Services
MACs paid providers approximately $885 million for selected polysomnography services provided to Medicare beneficiaries from January 1, 2017 through December 31, 2018. The OIG identified in prior audits payments being made with inappropriate diagnosis codes, without documentation supportive of the services provided and to providers exhibiting questionable billing patterns. These findings in combination with increased spending as noted above prompted the OIG to conduct additional audits. This month, the OIG has released reports for two polysomnography audits.
- OIG Report: Peninsula Regional Medical Center: Audit of Medicare Payments for Polysomnography
- 10 of 100 randomly selected beneficiary claims included 12 lines of service that did not comply with Medicare requirements. Based on the net overpayments of $17,499, the OIG estimated that Peninsula received at least $66,647 in overpayments for polysomnography services during the audit period.
- OIG Report: North Mississippi Medical Center: Audit of Medicare Payments for Polysomnography
- 12 of 100 randomly selected beneficiary claims included 13 lines of services that did not comply with Medicare requirements. Based on the next overpayments of $7,624, the OIG estimated that North Mississippi received at least $67,038 in overpayments for polysomnography services during the audit period.
CMS included the following additional resources for Providers related to correct billing for Polysomnography services in the March 18, 2021 edition of their weekly eNewsletter, MLN Connects:
- Provider Compliance Tips for Polysomnography (Sleep Studies) (PDF)fact sheet to help you bill correctly.
- Medicare Claims Processing Manual, Chapter 15 (PDF), Section 70
- Questionable Billing for Polysomnography ServicesOIG Report.
Claims Processing Instructions for National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs)
- Article Release Date: March 23, 2021
- What You Need to Know: This article provides follow-up instructions for the MACs related to Medicare claims processing system changes for ICDs with dates of service on or after February 15, 2018. Note, the implementation date for the related Change Request (CR) 12104 is July 6, 2021.
- MLN MM12104: https://www.cms.gov/files/document/mm12104.pdf
- CR 12104: https://www.cms.gov/files/document/r10635CP.pdf
MEDICARE EDUCATIONAL RESOURCES
MLN Booklet: Behavioral Health Integration Services
- Updated March 2021
- What You Need to Know: CMS made the following updates to this MLN Booklet:
- Added CY 2021 MPFS Final Rule CMS-1734-F Updates
- Added new HCPCS code G2214 - Initial or subsequent psychiatric collaborative care management, first 30 minutes in a month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional
- MLN909432 March 2021: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdf
MLN Booklet: Evaluation and Management Service Guide
- Updated February 2021
- What You Need to Know: This MLN education guide has been updated with 2021 Medicare Physician Fee Schedule final rule dates and links.
- MLN906764 February 2021: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf
January 2021 Medicare Quarterly Compliance Newsletter
CMS Posted a link to this newsletter in the March 18, 2021 MLN Connects eNewsletter. In this quarter’s newsletter you can learn about:
- Prefabricated and custom-fabricated knee orthoses: medical necessity and documentation requirements, and
- Ankle-foot orthoses and knee-ankle foot orthoses within the reasonable useful lifetime: excessive units.
March 15, 2021” Medicare Learning Network® (MLN) Provider Compliance Products
CMS published a list of Provider Compliance Education Products. These products provide education on how to avoid common coverage and coding/billing errors (i.e. Complying with Medical Record Documentation Requirements (MLN909160), Complying with Medicare Signature Requirements (MLN905364), and Provider Compliance Tips for Polysomnography (Sleep Studies) (MLN4013531)).
- MLN909307 March 2021: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProvCmpl_Products.pdf
OTHER MEDICARE UPDATES
Happy National Nutrition Month®
CMS included the following information in the March 4th edition of MLN Connects:
“Did you know that Medicare covers the following preventive services for nutrition-related health conditions like diabetes, chronic kidney disease, and obesity?
- Medical nutrition therapy
- Diabetes screening
- Diabetes self-management training
- Intensive behavioral therapy for obesity
- Intensive behavioral therapy for cardiovascular disease
- Annual wellness visit
During National Nutrition Month®, encourage your patients to develop healthy eating patterns and make food choices to meet their individual nutrient needs, goals, backgrounds, and tastes. More Information:
- Medicare Preventive Services Educational Tool
- Preventive Serviceswebpage
- National Nutrition Monthwebsite —“Personalize Your Plate”
- National Institute of Diabetes and Digestive and Kidney Diseaseswebsite
- Million Hearts®website
- Find a Registered Dietitian/Nutritional Professional”
Information for your patients on nutritional therapy services, diabetes screenings, diabetes self-management training, obesity behavioral therapy, cardiovascular behavioral therapy, and yearly “wellness” visits
MLN Fact Sheet: Health Professional Shortage Area Physician Bonus Program
This fact sheet explains how the Medicare Health Professional Shortage Area (HPSA) Physician Bonus Program works. It has information about how to get bonus payments when you deliver Medicare-covered services to patients in a geographic HPSA. Key Takeaways noted in this Fact Sheet includes:
- HPSAs are geographic areas of populations that lack enough health care providers to meet the health care needs of that population.
- CMS pays a 10 percent bonus payment when health care providers deliver Medicare-covered services to patients in a geographic HPSA.
- CMS pays HPSA bonuses quarterly based on the amount paid for professional services.
Link to MLN Fact Sheet (ICN MLN903196) February 2021: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/HPSAfctsht.pdf
March 17, 2021: American Hospital Association (AHA) Response to the American Rescue Plan Act of 2021 (ARP)
President Biden signed this $1.9 trillion coronavirus relief plan into law on March 11, 2021. In a related American Hospital Association Legislative Advisory, AHA notes their concern “that the law does not include an extension of relief from Medicare sequester cuts, which will go back into effect at the beginning of next month, and also fails to provide loan forgiveness for Medicare accelerated payments for hospitals.”
You can read more about the ARP Act of 2021 in related HHS and CMS Fact Sheets:
- Link to HHS Fact Sheet: https://www.hhs.gov/about/news/2021/03/12/fact-sheet-american-rescue-plan-reduces-health-care-costs-expands-access-insurance-coverage.html
- Link to CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/american-rescue-plan-and-marketplace
March 12, 2021: CMS Published Lists of Participants for Emergency Triage, Treat and Transport (ET3) Model
Link to Model CMS webpage:
link to Press Release: https://www.cms.gov/newsroom/press-releases/cms-announces-final-participants-emergency-triage-treat-and-transport-et3-model-furthers-commitment
March 18, 2021: MLN Connects Clinical Laboratory Data Reporting Delayed Until 2022 Reminder
CMS included the following information regarding the Protecting Access to Medicare Act of 2014 (PAMA) data collection and reporting periods:
For Clinical Diagnostic Laboratory Tests that are not Advanced Diagnostic Laboratory Tests, the requirement for you to report private payor data between January 1 and March 31, 2020, was delayed 2 years. You must report data from the original collection period. Reporting will resume on a 3-year cycle beginning in 2025. (Section 3718 of the Coronavirus Aid, Relief, and Economic Security Act). Current timeline:
- Collect Data for January 1 through June 30, 2019
- Report data between January 1 and March 31, 2022
For more information, see the PAMA Regulations webpage.
March 17, 2021: Medicare Coverage of Innovative Technology (MCIT) and Definition of “Reasonable and Necessary” Final Rule Delayed
CMS published an interim final rule in the Federal Register in keeping with the January 20, 2021 “Regulatory Freeze Pending Review” Memorandum. The Final Rule is being delayed until May 15, 2021. CMS is seeking public comments through April 16, 2021. In addition to operational practicalities cited by CMS as making them incapable of implementing the MCIT program on March 15, 2021, CMS notes the following additional reasons:
- “The higher than anticipated volume of devices receiving FDA breakthrough device designation exponentially complicates the operational concerns that we have identified. Further, public comments highlighted the importance of the agency having the ability to not only cover an FDA-designated breakthrough device expeditiously, but also to be able to have coding and payment levels established at the same time.”
Beth Cobb
MEDICARE MLN ARTICLES & TRANSMITTALS – RECURRING UPDATES
April 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
- Article Release Date: February 23, 2021
- What You Need to Know: This article informs providers about the Average Sales Price (ASP) methodology, which is based on quarterly data manufacturers submit to CMS.
- MLN Article MM12133: https://www.cms.gov/files/document/mm12133.pdf
Quarterly Updated for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) – April 2021
- Article Release Date: February 23, 2021
- What You Need to Know: The DMEPOS CBP files are updated on a quarterly basis to implement necessary changes to HCPCS codes, ZIP codes, single payment amounts, and supplier files.
- MLN Article MM12128: https://www.cms.gov/files/document/mm12128.pdf
OTHER MEDICARE MLN ARTICLES & TRANSMITTALS
Review of Hospital Compliance with Medicare’s Transfer Policy with Resumption of Home Health Services & Other Information on Patient Discharge Status Codes
- Article Release Date: February 22, 2021
- What You Need to Know: CMS reminds providers that an accurate discharge status code is essential to assure proper payment under the Medicare Severity-Diagnosis Related Group (MS-DRG) payment system. Detailed information regarding the CMS Transfer Policy is included in this article.
- MLN Article SE21001: https://www.cms.gov/files/document/se21001.pdf
Billing for Services when Medicare is a Secondary Payer
- Article Release Date: February 23, 2021
- What You Need to Know: CMS details what to do if you think a claim was inappropriately paid and provides key reminders related to billing for services when Medicare is a secondary payer.
- MLN Article SE21002: https://www.cms.gov/files/document/se21002.pdf
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits
- Article Release Date: February 23, 2021
- What You Need to Know: New HCPCS codes for 2021 that are subject to and excluded from CLIA edits are discussed in this article.
- MLN Article MM12131: https://www.cms.gov/files/document/mm12131.pdf
MEDICARE EDUCATIONAL RESOURCES
MLN Fact Sheet: Intravenous Immune Globulin (IVIG) Demonstration (Demonstration Ends on December 31, 2023)
The IVIG demonstration began in October 2014, has been extended twice, and is now set to end on December 31, 2023. This MLN Fact Sheet, dated February 2021, provides education on the IVIG demonstration and includes information on:
- Supplier eligibility and participation,
- Beneficiary eligibility and participation, and
- Billing and coding requirements.
OTHER MEDICARE UPDATES
Medicare Mid-Build Off-Campus Outpatient Department Exception Audit Results
On February 2nd CMS posted a webpage dedicated to their 21st Century Cures Act Mid-Build Audits. In overview, the Cures Act provided the criteria which off-campus departments of a provider must meet to comply with Mid-build exception requirements. CMS completed 334 provider audits that requested the mid-build exception. They found that 202 of the facilities failed to qualify for the exception. They note in the audit findings that “Providers that failed the mid-build exception audit and have been billing for the services provided by their off-campus provider-based departments under the OPPS, likely have received overpayments. Also, providers that have passed the mid-build exception audit and have not been billing for the services provided by their off-campus provider-based departments under the OPPS, likely have been underpaid.
CMS will issue audit determination letters to all affected providers on January 19, 2021. The letter will provide the final determination on meeting the exception, the appropriate point of contact information, and further instructions. The 21st Century Cures Act states that the mid-build exception audit determinations are final and may not be appealed.” The Audit Results and FAQ documents are available on this CMS webpage.
Improving Accuracy of Medicare Payments
CMS shared the following information in the Thursday February 4, 2021 Edition of MLN Connects:
The U.S. Bureau of Labor Statistics (BLS) conducts numerous surveys of hospitals and health care providers that are used by the government to make economic decisions that affect the entire medical care system. Key users include CMS, the Federal Reserve Bank, and the U.S. Congress. CMS uses these surveys to adjust Medicare Fee-for-Service payments each year, affecting approximately $300 billion in payments.
If you’re contacted by BLS, please participate in the survey to help ensure the data are as accurate as possible. Recently, many health care providers didn’t complete the survey, which can reduce the representativeness of the data and increase volatility in estimates. Your participation in these surveys helps address these issues and increase the validity of the data. Participation is voluntary, confidential, and the data are only used for statistical purposes.
More Information:
- BLS Survey Respondentswebpage
- BLS Confidentiality Pledge and Lawswebpage
- CMS Market Basket Datawebpage
- BLS Geographic Informationwebpage: Contact a BLS expert or get information on surveys, data, and reports”
February 22, 2021: OIG Report – $4 Million in improper payments for Spinal Facet-Joint Injections
The OIG found that 49 of 100 sampled claims were inappropriately paid by Noridian Healthcare Solutions, LLC to physicians in Jurisdiction E for spinal facet-joint injections. They note that improper payments occurred due to insufficient education to physicians and their billing staff. Based on their findings, the OIG estimated that $4.2 million was improperly paid to physicians. Recommendations for Noridian included recovering the $12,546 in improper payments found in the sampled claims, notify appropriate physicians so they can identify, report, and return any overpayments in accordance with the 60-day rule and provide annual training to physicians and their billing staff. You can read the entire report at https://oig.hhs.gov/oas/reports/region9/92003010.pdf.
Beth Cobb
Yes! Help me improve my Medicare FFS business.
Please, no soliciting.
We are an environmentally conscious company, dedicated to living “green” both at work and as individuals.
