Health Information Management

The week in Medicare updates

HIM-HIPAA Insider, April 20, 2015

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CMS updates information for billing screening services

On April 3, CMS released a change request to ensure accurate program payment for three screening services for which the beneficiary should not be charged the coinsurance or deductible. The coinsurance and deductible for these services are currently waived. Due to coding changes and additions to the Medicare Physician Fee Schedule Database, the payments for CY 2015 would not be accurate without this change request for intensive behavioral group therapy for obesity, digital breast tomosynthesis, and anesthesia associated with colorectal cancer screening tests. Transmittal 3160, dated January 7, 2015, is being rescinded and replaced by Transmittal 3232 to remove the references to coinsurance and deductible from BR 8874.10.1, add modifier -PT and the inapplicability of the deductible to BR 8874.10.1.1, expand the range of surgical services to which modifier -PT applies in BR 8874.10.1.1, add CWF responsibility to BR 8874.10.1.1, and to add modifier -PT to BR 8874.10.1.2. The Medicare Claims Processing Manual, Chapter 18, section 1.2, Table of Preventive and Screening Services, is changed to add a sentence to the NOTE concerning billing with modifier -PT before code G0104 and Chapter 18, section 60.1.1, is changed to add a sentence concerning billing with modifier -PT. All other information remains the same.
 
Effective date: January 1, 2015
Implementation date: January 5, 2015
 
View Transmittal R3232CP.
View MLN Matters article MM8874.
 
CMS releases changes to the laboratory NCD software for July 2015
On April 3, CMS released a transmittal announcing the changes to be included in the July 2015 quarterly release of the edit module for clinical diagnostic laboratory services. The NCDs for clinical diagnostic laboratory services were developed by the laboratory negotiated rulemaking committee and the final rule was published on November 23, 2001. Nationally uniform software was developed and incorporated in the Medicare shared systems so that laboratory claims subject to one of the 23 NCDs were processed uniformly throughout the nation effective April 1, 2003. This recurring update notification applies to Publication (Pub) 100-03, NCD Manual, Chapter 1, section 190, and Pub 100-04, Medicare Claims Processing Manual, Chapter 16, section 120.2.
 
Effective date: October 1, 2015
Implementation date: July 6, 2015
 
View Transmittal R3228CP.
View MLN Matters article MM9124.
 
Updates on hospice election form, revocation, and attending physician released
On April 3, CMS released an instruction implementing changes finalized in the FY 2015 hospice rule regarding hospice election, revocation, and designation of attending physician. This transmittal is regarding Medicare Benefit Policy Manual, Publication 100-02.
 
Effective date: May 4, 2015
Implementation date: May 4, 2015
 
View Transmittal R205BP.
View MLN Matters article MM9114.
 
Contractors may adjust codes instead of denying entire claims
On April 3, CMS released a change request to allow the MACs, Supplemental Medical Review Contractor (SMRC), Comprehensive Error Rate Testing (CERT) contractor, Zone Program Integrity Contractors (ZPICs) and Recovery Auditors to not deny the entire claim when the medical record supports a higher or lower level code, but instead to adjust the code and the payment. The MACs, SMRC, ZPICs, CERT and Recovery Auditors shall up code or down code when it is possible to pay for the item or service actually provided without making a reasonable and necessary determination or if otherwise specified in applicable CMS medical review instructions. The MACs, SMRC, ZPICs, CERT and Recovery Auditors shall not substitute the payment amount of one item or service for a different item or service based on a reasonable and necessary determination.
 
Effective date: May 4, 2015
Implementation date: May 4, 2015
 
View Transmittal R585PI.
 
CMS updates Medicare Internet-Only Manual chapters for SNF providers
On April 3, CMS released an instruction updating various sections of the internet-only manual chapters in regards to SNF policy and billing. Transmittal 3216, dated March 13, 2015, is being rescinded and replaced by Transmittal 3230 to delete sections 30.5.1, 30.6 and 30.7 in Chapter 6 as this information has been reorganized to sections 30.3, 30.4 and 30.5, respectively. All other information remains the same.
 
Effective date: June 15, 2015
Implementation date: June 15, 2015
 
View Transmittal R3230CP.
View MLN Matters article MM8997.
 
CMS clarifies off-premise activities requirements and approval of extension locations for some outpatient services
On April 3, CMS posted a survey and certification letter regarding additional guidelines to the State Operations Manual Chapter 2 to clarify certification requirements for providers of outpatient physical therapy (OPTs). OPTs may only provide services at off-premises locations, such as ALFs/ILFs, on an intermittent basis when there is no ongoing or permanent presence of the OPT. CMS clarifies that a patient’s room, and by extension, common areas within an ALF or ILF may be considered a patient’s residence and may be exempt from the OPT two-person duty requirement. Extension locations may be approved when they are located outside the immediate vicinity of the primary site.
 
View the survey and certification letter.
 
CMS posts alert regarding gastrointestinal endoscopies
On April 3, CMS posted an alert regarding recent newspaper articles, medical publications, and adverse event reports associate multidrug-resistant bacterial infections caused by CRE with patients who have undergone endoscopic retrograde cholangiopancreatography (ERCP). Duodenoscopes used to perform ERCP are difficult to clean and disinfect, even when manufacturer reprocessing instructions are followed correctly, and have been implicated in these outbreaks. The FDA has issued a Safety Communication warning, with related updates, that the design of duodenoscopes may impede effective cleaning. Hospitals, critical access hospitals, and ASCs are expected to meticulously follow the manufacturer’s instructions for reprocessing duodenoscopes, as well as adhere to the nationally recognized Multisociety consensus guidelines developed by multiple expert organizations and issued in 2011.
 
View the survey and certification letter.
 
CMS posts technology assessment for pain management injection therapies for low back pain
On April 7, CMS posted a technology assessment regarding for pain management therapies for low back pain. This report reviews the current evidence on effectiveness and harms of epidural, facet joint, and sacroiliac corticosteroid injections for low back pain conditions.
 
View the technology assessment.
 
CMS revises State Operations Manual, Appendix W for Critical Access Hospitals
On April 7, CMS released a change request revising Appendix W, Survey Protocol, Regulations and Interpretive Guidance for Critical Access Hospitals (CAH) and Swing Beds in CAHs to reflect recent regulation changes. CMS made clarifications and updates to existing guidance. The table of contents was revised to remove the reference to Standards and only reflect the Conditions. Tag C-0299 is new and has been added to reflect the new Interpretive Guidelines for §485.635(e). Tag C-0286 has been deleted and the revised Interpretive Guidelines have been relocated to tag C-0287. Tag C-0290 has been deleted and the Interpretive Guidelines have been relocated to C-0287 and to Tag C-0288. Tag C-0293 has been deleted and the Interpretive Guidelines have been relocated to tag C-0292. Tag C-0295 has been deleted and the revised Interpretive Guidelines have been relocated to Tac C-0294
 
Effective date: April 7, 2015
Implementation date: April 7, 2015
 
View Transmittal R138SOM.
 
Mass adjustment of OPPS claims with APC 1448
On April 9, CMS announced that, for OPPS claims with APC 1448 (ophthalmic mitomycin), the national unadjusted copayment was erroneously set to 20% instead of $0 for claims with dates of service of January 1, 2014, through claims received prior to the installation of the April 2015 OPPS Pricer. The error has been corrected in the April 2015 OPPS Addendums A and B, as well as in the release of the April 2015 OPPS Pricer.
 
MACs will be mass adjusting affected claims to issue corrected payments. Providers must reimburse beneficiaries for any overpayment of copayment caused by this error.
 
View the announcement.
 
Medicare Quarterly Provider Compliance Newsletter, April 2015
MLN Matters released the April 2015 edition of the Medicare Quarterly Provider Compliance Newsletter.
 
View the newsletter.



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