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The week in Medicare updates

HIM-HIPAA Insider, July 13, 2015

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CMS releases 2016 proposed hospital OPPS rule

On July 1, CMS released CMS-1633-P, the CY 2016 hospital outpatient prospective payment system (OPPS) and ambulatory surgery center (ASC) payment system policy changes, quality provisions, and payment rates proposed rule. It proposes updates to Medicare payment policies and rates for hospital outpatient departments, ASCs, and partial hospitalization services provided by community mental health centers, and changes that encourage high-quality care in these outpatient settings. This proposed rule also includes important proposed changes to the 2-midnight rule for CY 2016. Comments are due August 31.

View CMS-1633-P.
View the fact sheet.
View the fact sheet on the 2-midnight rule.
Leave a comment.

CMS releases payment rate updates for skilled nursing facilities in 2016

On June 26, CMS released a transmittal to provide information on the updates to the Medicare Part A payment rates used under the prospective payment system for skilled nursing facilities for FY 2016, as required by statute. The update can be found in Chapter 6, Section 30.7 of the Medicare Claims Processing Manual.

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

View Transmittal R3286CP.
View MLN Matters article MM9222.

CMS proposes updates to policies and payment rates for end-stage renal disease facilities and quality incentive program

On June 26, CMS posted a fact sheet regarding a proposed rule that will update payment policies and rates under the end-stage renal disease (ESRD) prospective payment system for renal dialysis services furnished to beneficiaries on or after January 1, 2016. This rule also proposes new quality and performance measures to improve the quality of care by dialysis facilities treating patients with ESRD.

View the fact sheet.

Clarification of critical access hospitals’ rural status, location, and distance requirements

On June 26, CMS posted a memorandum superseding the portion of the guidance of policy memorandum S&C 11-33, which addresses metropolitan statistical areas. That guidance is being updated to reflect the new critical access hospital (CAH) regulation at 42 CFR 485.610(b)(5). Under the new regulation, a Medicare-participating CAH previously located in a rural area may no longer be located in a rural area when CMS adopts the most recent Office of Management and Budget (OMB) delineations. Such CAHs are permitted to retain their CAH status up to two years from the effective date of CMS’ latest adoption of the OMB delineations. During this grace period, the CAHs are expected either to reclassify as rural under one of the alternatives or to convert to a Medicare-participating hospital. The guidance found in Chapter 2 and Appendix W of the State Operations Manual (SOM) is being updated to specify that the proximity to each other of Indian Health Services (IHS)/Tribal hospitals/CAHs and non-IHS/Tribal hospitals/CAHs is not considered when a CAH location determination is made. The guidance in Chapter 2 and Appendix W of the SOM is also being updated to reflect the location and distance requirements relative to CAHs located on islands. The criteria for a primary road have been refined.

View the survey and certification letter.

Use of portable reverse osmosis units and block carbon

On June 26, CMS posted a survey and certification letter regarding portable reverse osmosis (RO) units that meet Association for the Advancement of Medical Instrumentation water quality standards, as incorporated by reference in the end-stage renal disease (ESRD) Condition for Coverage at 42 CFR Section 494.40, that may be used in outpatient dialysis facilities. ESRD Surveyors should follow the ESRD Core Survey process in conjunction with this guidance for use of portable RO units and block carbon in outpatient dialysis facilities.

View the survey and certification letter.

SAMHSA reports improved outcome measures for substance abuse grant program

On June 29, the OIG posted a report stating SAMHSA leads public health efforts to improve the quality and availability of prevention and treatment services for substance abuse and mental illness. One such effort is the Substance Abuse Prevention and Treatment Block Grant (SABG) program, which provides more than $1.7 billion each fiscal year to states, territories, and tribes to prevent and treat substance abuse. In 2003, the Office of Management and Budget had rated the SABG program as ineffective and given it a low score on program results and accountability; however, in recent years, SAMHSA reports it has made significant strides in improving performance and outcome measurement for its block grant programs, including SABG.

View the report.

Revisions to Medicare Claims Processing Manual for foreign, emergency, and shipboard claims

On June 30, CMS rescinded Transmittal 3199 and replaced it with Transmittal 3287 to re-designate sections 340 & 350 to sections 350 & 360, respectively. All other information remains the same. This change request revises the instruction found in the Medicare Claims Processing Manual for processing foreign, emergency, and shipboard claims.

Effective date: April 21, 2015
Implementation date: April 21, 2015

View Transmittal R3287CP.

Compliance review finds Kentucky hospital overbilled Medicare for $209,000

On June 30, the OIG posted a report detailing a Medicare Compliance Review of University of Kentucky HealthCare that found the hospital did not fully comply with billing requirements for all its Medicare claims between 2011 and 2012, resulting in $209,000 in overpayments. The hospital did comply with Medicare billing requirements on 154 of 232 inpatient and outpatient claims reviewed, but was found noncompliant on the remaining 78 claims.

View the complete report.

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