Corporate Compliance

This week in Medicare updates

Medicare Insider, August 18, 2015

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October CY 2015 quarterly update to the Medicare physician fee schedule database

On August 6, CMS released a change request amending payment files that were issued to contractors based upon the CY 2015 Medicare physician fee schedule (MPFS) final rule. This recurring update notification applies to Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, section 30.1.

Effective date: January 1, 2015
Implementation date: October 5, 2015

View Transmittal R3317CP.

View MLN Matters article MM9266.

Medicare payments when liability set asides exhaust

On August 6, CMS released a change request related to set asides from worker’s compensation arrangements and Ongoing Responsibility for Medicals (ORM) funds from Non-Group Health Plans (NGHP) such as liability and no-fault insurance. When these funds are exhausted mid-stay or mid-visit and do not fully compensate the provider for the visit or stay, the shared systems, the A/B MACs, and DME MACs are instructed to pay residual secondary payment. The shared system or MACs are instructed to send the primary payer amounts from the set aside or ORM funds to the MSPPAY module and calculate Medicare’s payment if such services are covered and reimbursable by Medicare.

Effective date: January 1, 2016
Implementation date: January 4, 2016

View Transmittal R113MSP.

October 2015 quarterly update of HCPCS drug/biological code changes

On August 6, CMS released the quarterly update of the HCPCS code set. This instruction informs the contractors of updated specific drug/biological HCPCS codes. Beginning in October 2015, a temporary HCPCS code will be established for alemtuzumab (Lemtrada®).

Effective date: October 1, 2015
Implementation date: October 5, 2015

View Transmittal R3304CP.

View MLN Matters article MM9273.

Claims processing instructions for diagnostic digital breast tomosynthesis

On August 6, CMS released a change request providing claims processing instructions for HCPCS code G0279 (diagnostic digital breast tomosynthesis, unilateral or bilateral [list separately in addition to G0204 or G0206]).

Effective date: January 1, 2016
Implementation date: January 4, 2016

View Transmittal R3301CP.

View MLN Matters article MM9191.

New and revised Place of Service (POS) codes for outpatient hospital

On August 6, CMS released a change request revising the description of POS code 22 to On Campus-Outpatient Hospital and creates a new POS code 19 for Off Campus-Outpatient Hospital.

Effective date: January 1, 2016
Implementation date: January 4, 2016

View Transmittal R3315CP.

View MLN Matters article MM9231.

Applying therapy caps to Maryland hospitals

On August 6, CMS released a change request revising Original Medicare systems to ensure therapy services provided in Maryland hospitals are subject to the outpatient therapy per-beneficiary caps. The update also added several sections discussion therapy caps, including documentation and the -KX modifier.

Effective date: January 1, 2016
Implementation date: January 4, 2016

View Transmittal R3309CP.

View MLN Matters article MM9223.

Medicare Remit Easy Print (MREP) upgrade

On August 6, CMS released a change request instructing the developer of the software to update based on enhancement requests received through the MACs and/or the CMS website. This software is available free of charge from the CMS website and now offers a number of special reports that users can view and download in addition to the remittance advice.

Effective date: January 1, 2016
Implementation date: January 4, 2016

View Transmittal R1524OTN.

View MLN Matters article MM9203.

SNF Medicare FY 2016 Payments, Quality Reporting, Value-Based Purchasing and Staffing Data Collection Requirements final rule–Informational Only

On August 7, CMS posted a survey and certification letter regarding the final rule published on August 4, 2015, which implements the new requirements regarding the submission of staffing data to CMS based on payroll and other verifiable and auditable data. Effective July 1, 2016, long-term care facilities that participate in Medicare and Medicaid must electronically submit direct care staffing information (including information for agency and contract staff) based on payroll and other verifiable and auditable data in a uniform format to CMS. Registration began August 4, 2015, for facilities to register for the voluntary submission period which begins October 1, 2015.

View the survey and certification letter.

National Site Visit Verification (NSV) initiative

On August 11, CMS released a special edition MLN Matters article providing the latest information about the CMS NSV initiative. The NSV initiative is part of CMS’ National Fraud Prevention Program and assists CMS in its efforts to prevent fraud and abuse in the Medicare program starting with the enrollment process.

View the special edition MLN Matters article SE1520.

OIG advisory opinion No. 15-11

On August 12, the OIG responded to a request for an advisory opinion regarding a program to provide a drug for free for a limited time to patients who experience a delay in the insurance approval process.

View the opinion.

CMS posts information on 2-midnight rule updates in the OPPS proposed rule

On August 12, CMS updated its Inpatient Hospital Reviews website to reflect the updates proposed in the CY 2016 OPPS proposed rule to the 2-midnight rule regarding when inpatient admissions are appropriate for payment under Medicare Part A. The proposed rule also notified the public of upcoming changes in education and enforcement strategies. These changes were also discussed in a related Fact Sheet.

View the website.

View the fact sheet.

Wolters Kluwer clinical drug information Lexi-Drugs Compendium revision request

On August 12, CMS posted a decision regarding the formal addition of Lexi-Drugs to the list of compendia used by the Medicare program in the determination of a "medically accepted indication" for off-label drugs and biologics used in an anticancer chemotherapeutic treatment regimen.

View the decision.

Limiting the Scope of Review on redeterminations and reconsiderations of certain claims

On August 13, CMS released special edition MLN Matters article SE1521 to inform providers of the clarification CMS has given to the MACs and Qualified Independent Contractors (QIC) regarding the scope of review for redeterminations. This updated instruction applies to redetermination requests received by a MAC or QIC on or after August 1, 2015, and will not be applied retroactively.

View special edition MLN Matters article SE1521.

Bundled Payments for Care Improvement Initiative (BPCI) fact sheet

On August 13, CMS posted a fact sheet regarding the BPCI initiative. The BPCI is composed of four broadly defined care models that bundle payments for multiple services beneficiaries received during an episode of care. Under the initiative, organizations enter into payment arrangements that include financial and performance accountability for an entire episode. These models may lead to higher quality and more coordinated care for beneficiaries at a lower cost to Medicare.

View the fact sheet.

View the press release.

Overlap between physician-owned hospitals and physician-owned distributors

On August 14, the OIG posted a report that follows up on its October 2013 report Spinal Devices Supplied by Physician Owned Distributors: Overview of Prevalence and Use (OEI-01-11-00660), which found that physician owned distributors (POD) supplied the devices used in nearly one in five spinal fusion surgeries billed to Medicare. When OIG met with CMS in September 2013 to discuss a draft of the report, agency staff expressed interest in the overlap between owners of physician-owned hospitals and PODs of spinal devices.

View the report.

ICD-10 Coordination and Maintenance Committee Meeting

CMS announced its ICD-10 Coordination and Maintenance Committee Meeting to take place on September 22 and September 23. The first day of the meeting, September 22, will be devoted to procedure code issues. The second day of the meeting, September 23, will be devoted to diagnosis code topics.

Register for the meeting.



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