Health Information Management

The week in Medicare updates

APCs Insider, April 17, 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, but 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Transmittal 3160, dated January 7, 2015, is being rescinded and replaced by Transmittal 3232.
Effective date: January 1, 2015
Implementation date: January 5, 2015 
View Transmittal R3232CP
View MLN Matter article MM8874.
Laboratory NCD software updated for July
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 National Coverage Determinations (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 the NCD Manual, Chapter 1, section 190, and the 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.
Contractors may adjust codes instead of denying entire claims
On April 3, CMS released a change request to allow MACs, Supplemental Medical Review Contractors (SMRC), Comprehensive Error Rate Testing (CERT) contractors, 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. Instead they should adjust the code and the payment.
The MACs, SMRC, ZPICs, CERT, and Recovery Auditors will upcode or downcode 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 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 (SOM) Chapter 2 to clarify certification requirements for providers of outpatient physical therapy. Outpatient therapists (OPT) may only provide services at off-premises locations 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 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 carbapenem-resistant enterobacteriaceae (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 consensus guidelines developed by multiple expert organizations and issued in 2011. 
View the survey and certification letter.
Technology assessment for pain management injection therapies for low-back pain posted
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.
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.
CMS releases April quarterly newsletter 
MLN Matters released the April 2015 edition of the Medicare Quarterly Provider Compliance Newsletter
View the newsletter.

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