The week in Medicare updates
HIM-HIPAA Insider, August 25, 2014
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CMS provides examples of claims that are related
On August 8, CMS released a change request to allow the MACs and ZPICs the discretion to deny claims that are "related" and provide approved examples of such situations.
Effective date: September 8, 2014
Implementation date: September 8, 2014
View Transmittal R534PI.
Automation of the Request for Reopening claims process
On August 8, CMS released a change request to implement National Uniform Billing Committee (NUBC) approved bill type and condition codes for a request for reopening. CMS, in an effort to streamline and standardize the requesting process, had petitioned the NUBC for a new bill type frequency code that providers can use to indicate a Request for Reopening and a series of condition codes that can be used to identify the type of reopening being requested. Upon adoption of these NUBC changes, CMS can move forward with implementation of necessary system changes to accommodate this process.
On August 14, CMS also released a related special edition MLN Matters article that details actions to take when a provider needs to reopen a claim beyond the claims timely filing limit.
Effective date: October 1, 2014-analysis and design (CWF, FISS and FISS USERS); Claims received on or after January 1, 2015 - (CWF, FISS and FISS USERS)
Implementation date: October 6, 2014-analysis and design (CWF, FISS and FISS USERS); January 5, 2015-coding; and April 6, 2015 – full implementation (CWF, FISS and FISS USERS)
View Transmittal R3022CP.
View MLN Matters article MM8581.
View MLN Matters Special Edition article SE1426.
View MLN Matters article MM8581.
View MLN Matters Special Edition article SE1426.
October 2014 Integrated Outpatient Code Editor (I/OCE) specifications version 15.3
On August 8, CMS released a notification to provide the October 2014 quarterly update to the I/OCE instructions and specifications that will be used under OPPS and non-OPPS for hospital outpatient departments, community mental health centers, all non-OPPS providers. It will also be used 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 Recurring Update Notification applies to 100-04, Medicare Claims Processing Manual, Chapter 4, section 40.1.
Effective date: October 1, 2014
Implementation date: October 6, 2014
View Transmittal R3018CP.
Two new “K” codes for prefabricated knee orthosis that are furnished off-the-shelf (OTS)
On August 8, CMS released a change request stating that effective October 1, two new "K" codes will be established for prefabricated single and double upright knee orthosis that are furnished OTS. The addition of the codes will allow the durable medical equipment MACs to correctly adjudicate claims. This Recurring Update Notification applies to the Medicare Claims Processing Manual, Chapter 23, Section 20.
Effective date: October 1, 2014
Implementation date: October 6, 2014
Medicare Managed Care, Chapter 5, Quality Improvement Program (QIP) changes
On August 8, CMS released a change request revising Medicare Managed Care, Chapter 5, with new content and clarification of policy in the following areas: introduction, chronic care improvement and QIP, additional QIP program requirements for special needs plans, structure & process measures, MAO reporting requirements, MA deeming program, and definitions.
Effective date: August 8, 2014
Implementation date: August 8, 2014
View Transmittal R117MCM.
Critical access hospital (CAH) equipment maintenance requirements
On August 8, CMS stated that in accordance with 42 CFR 485.623(b)(1), CAHs are required to maintain all essential mechanical, electrical, and patient-care equipment in safe operating condition. A CAH may adjust its maintenance, inspection, and testing frequency and activities for facility and medical equipment from what is recommended by the manufacturer, based on a risk-based assessment except in certain situations. CAHs electing to adjust this maintenance must develop policies and procedures and maintain documentation supporting their Alternate Equipment Management (AEM) program and adhere strictly to the AEM activities and frequencies they establish.
View the survey and certification letter.
Update to hospice payment rates, cap, wage index, Quality Reporting Program and the Hospice Pricer for FY 2015
On August 11, CMS released a change request to update the hospice payment rates, hospice wage index, and pricer for FY 2015, and to update the hospice cap amount for the cap year ending October 31, 2014. This Recurring Update applies to Pub 100-04, Medicare Claims Processing Manual, Chapter 11, section 30.2.
Effective date: October 1, 2014
Implementation date: October 6, 2014
Proposed decision memorandum for screening for colorectal cancer
On August 11, CMS proposed that the evidence is sufficient to cover CologuardTM–a multitarget stool DNA test–as a colorectal cancer screening test for asymptomatic average risk beneficiaries aged 50 to 85 years.
View the proposed decision memorandum.
Government Accountability Office (GAO) study on effectiveness and efficiency of contractor post-payment claims reviews
On August 13, GAO released a study regarding several types of Medicare contractors conducting post-payment claims reviews to help reduce improper payments. Questions have been raised about their effectiveness and efficiency, and the burden on providers. GAO was asked to assess aspects of the claims review process.
View the GAO report.
Comments request on Hospital Conditions of Participation and supporting regulations
On August 15, CMS posted a notice in the Federal Register announcing it is collecting comments regarding CMS–R–48, Hospital Conditions of Participation and Supporting Regulations. Comments are due by September 15.
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