Health Information Management

The week in Medicare updates

APCs Insider, July 24, 2015

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CMS revises July 2015 quarterly drug code updates
On July 10, CMS rescinded Transmittal 3254, dated May 8, 2015, and replaced it with Transmittal 3292, dated July 10, 2015, to modify business requirement 9167.5 and to clarify the use of HCPCS code Q9977 (compounded drug, not otherwise classified).
Effective date: July 1, 2015
Implementation date: July 6, 2015
View Transmittal R3292CP.
CMS releases October 2015 quarterly average sales price Part B drug pricing files and revisions to prior quarterly pricing files
On July 10, CMS released the average sales price (ASP) methodology based on quarterly data submitted to CMS by manufacturers. CMS will supply contractors with the ASP and not otherwise classified drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the OPPS are incorporated into the Outpatient Code Editor through separate instructions that can be located in Chapter 4 of the Medicare Claims Processing Manual, section 50, of the Internet-Only Manual. Contractors will not search and adjust claims that have already been processed unless brought to their attention.
Effective date: October 1, 2015
Implementation date: October 5, 2015
View Transmittal R3290CP.
View MLN Matters article MM9248.
CMS revises the State Operations Manual
On July 10, CMS released revised interpretive guidelines for 42 CFR 482.26 concerning radiologic services and 42 CFR 482.53 concerning nuclear medicine provided in hospitals.
Effective date: July 10, 2015
Implementation date: July 10, 2015
View Transmittal R141SOM.
CMS updates regulations for outpatient therapy threshold claims
On July 10, CMS posted that it set restrictions on the number of additional documentation requests that could be sent related to outpatient therapy threshold claims (claims over the $3,700 threshold) that were paid March 1, 2014, through December 31, 2014.
View the update.
Recovery Auditor requests for quotes withdrawn
On July 10, CMS posted that, effective June 4, 2015, it has withdrawn the requests for quotes for the next round of Recovery Auditor contracts. CMS plans to update the statement of work and release new requests for proposals shortly. In the meantime, the current Recovery Auditors will continue active recovery auditing through at least December 31, 2015.
View the update.
CMS issues notice of 2015 interest rate for Medicare overpayments and underpayments
On July 13, CMS released a transmittal stating the private consumer rate has been changed to 9.75%, which applies to charging and payment of interest on overpayments and underpayments to Medicare providers.
Effective date: July 20, 2015
Implementation date: July 20, 2015
View Transmittal R251FM.
Medicare contractor overpaid a provider that incorrectly billed for aflibercept
On July 13, the Office of Inspector General (OIG) posted a report stating that the Medicare contractor for Jurisdiction 1 (California, Hawaii, Nevada, American Samoa, Guam, and the Northern Mariana Islands) overpaid a provider that incorrectly billed for aflibercept by $707,000.
View the report.
OIG completes Medicare compliance review of Saint Mary's Health Center for 2011 and 2012
On July 13, the OIG posted a Medicare compliance review stating Saint Mary's Health Center, operating in Saint Louis, Missouri, complied with Medicare billing requirements for 181 of the 193 inpatient and outpatient claims it reviewed. However, the hospital did not fully comply with Medicare billing requirements for the remaining 12 claims, resulting in overpayments of $69,000 for 2011 and 2012 (10 claims) and 2010 (two claims).
View the report.
New CMS technology identifies and prevents $820 million in improper Medicare payments in first three years
On July 14, CMS posted a press release stating its advanced analytics system, called the Fraud Prevention System, identified or prevented $820 million in inappropriate payments in the program’s first three years. The Fraud Prevention System uses predictive analytics to identify troublesome billing patterns and outlier claims for action, similar to systems used by credit card companies.
View the press release.
View the report.
CMS announces extension of Medicare prior authorization for power mobility devices demonstration
On July 15, CMS posted a notice in the Federal Register announcing an extension of the Medicare prior authorization for power mobility devices demonstration. This demonstration will now end August 31, 2018.
View the notice in the Federal Register.

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