The week in Medicare updates
APCs Insider, August 22, 2014
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Contractors given discretion to deny 'related' claims
On August 8, CMS released a change request to allow 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 bill type and condition codes approved by the National Uniform Billing Committee (NUBC) 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 can be used by providers 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 MLN Matters® article. This article 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.
October 2014 I/OCE specifications version 15.3 released
On August 8, CMS released a notification to provide the October 2014 quarterly update to the Integrated OCE instructions and specifications that will be used under the OPPS and non-OPPS for hospital outpatient departments, community mental health centers, all non-OPPS providers. It is also 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 the 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 introduced for knee orthoses furnished off the shelf
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 orthoses that are furnished off the shelf. The addition of the codes will allow the durable medical equipment MACs to correctly adjudicate claims. This Recurring Update Notification applies to Medicare Claims Processing Manual, Chapter 23, section 20.
Effective date: October 1, 2014
Implementation date: October 6, 2014
View Transmittal R3016CP.
Medicare Managed Care, Chapter 5, revised
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 Quality Improvement Program (QIP), additional QIP program requirements for special needs plans, structure and process measures, reporting requirements, Medicare Advantage deeming program, and definitions.
Effective date: August 8, 2014
Implementation date: August 8, 2014
View Transmittal R117MCM.
Proposed decision memorandum colorectal cancer screening released
On August 11, CMS proposed that the evidence is sufficient to cover CologuardTM–a multi-target stool DNA test–as a colorectal cancer screening test for asymptomatic average risk beneficiaries aged 50 to 85 years.
View the proposed decision memorandum.
GAO releases study on effectiveness of contractor postpayment claims reviews
On August 13, the Government Accountability Office (GAO) released a study regarding several types of Medicare contractors conducting postpayment 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 requested 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.
View the notice in the Federal Register.
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