This week in Medicare updates–8/23/2017
Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) and Policy Changes and Fiscal Year 2018 Rates
On August 14, CMS published the FY2018 Inpatient Prospective Payment System Final Rule in the Federal Register. CMS finalized an increase in operating payment rates of approximately 1.2% for most hospitals, in addition to increasing the amount for uncompensated care payments by $800 million to approximately $6.8 billion for FY 2018. CMS also finalized their proposal to use Worksheet S-10 data moving forward to calculate uncompensated care payments, with an opportunity for hospitals to amend or submit Worksheet S-10 for FY2015 data by September 30 to ensure correct data for FY2019. CMS also issued clarifying instructions for completing Worksheet S-10 in response to commenters requests. CMS did not adopt its proposal to end the imputed rural floor, continuing the policy through FY2018 while it considers other options.
Effective date: October 1, 2017
Home Health Medical Review Update
On August 14, CMS announced several updates on its Home Health Medical Review website.
- CMS has developed a review tool that may be helpful in submitting claims that meet Medicare requirements. This tool, also located in the downloads section below, is not designed to be a comprehensive review tool, but was developed to help HHAs avoid the common denial reasons CMS has seen over the past few years.
- Medicare Administrative Contractors (MACs) have completed round 1 “probe and educate” reviews of home health claims for episodes that began on or after August 1, 2015. The round two reviews are expected to conclude in September.
The issues discovered as a result of the probe and educate reviews included:
- Issues related to the Face to Face requirements; including no signature by the certifying physician and encounter notes not supporting all of the elements of eligibility.
- Recertification with no estimate of continued need for service and recertification denials because the initial certification was missing/incomplete or invalid.
- The other major denial relates to claims denied for 56900, no response to the additional documentation request (ADR).
Quarterly Update to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS)
On August 14, CMS published MLM Matters 10193, which is related to CMS Medicare Claims Processing Manual Transmittal 3833, issued August 11, a recurring update notification updating the consolidated billing list under the ESRD PPS.
Effective date: October 1, 2017
Implementation dates: October 2, 2017
Proposed Changes to Comprehensive Care for Joint Replacement Model, Cancellation of Other Models
On August 15, CMS announced a Proposed Rule in the Federal Register to reduce the number of mandatory geographic areas participating in the Center for Medicare and Medicaid Innovation’s Comprehensive Care for Joint Replacement (CJR) model from 67 to 34. In addition, CMS proposes to allow CJR participants in the 33 remaining areas to participate on a voluntary basis. In this rule, CMS also proposes to make participation in the CJR model voluntary for all low volume and rural hospitals in all of the CJR geographic areas.
CMS also is proposing through this rule to cancel the Episode Payment Models and the Cardiac Rehabilitation incentive payment model, which were scheduled to begin on January 1, 2018. Eliminating these models would give CMS greater flexibility to design and test innovations that will improve quality and care coordination across the in-patient and post-acute-care spectrum.
Comments are due by October 16, 2017.
CMS also issued a Fact Sheet and a Press Release on August 15.
For further information, please see the CJR Model webpage and the Episode Payment Models: General Information webpage.
Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2018
On August 15, CMS released MLM Matters 10131, which is related to CMS Medicare Claims Processing Manual Transmittal 3828, published August 4. Both the MLM Matters and the Transmittal explore updates the hospice payment rates, wage index, and Pricer for FY 2018. It also updates the hospice cap amount for the year ending October 31, 2017.
Effective date: October 1, 2017
Implementation dates: October 2, 2017
CMS Releases Hospice Compare Website
On August 16, CMS issued a Press Release announcing its new Hospice Compare website. The site displays information in a ready-to-use format and provides a snapshot of the quality of care each hospice facility offers to its patients. The Hospice Compare site allows patients, family members, caregivers, and healthcare providers to compare hospice providers based on important quality metrics, such as the percentage of patients that were screened for pain or difficult or uncomfortable breathing, or whether patients’ preferences are being met. Currently, the data on Hospice Compare is based on information submitted by approximately 3,876 hospices.
CMS also released a Fact Sheet on the matter the same day.
Screening for the Human Immunodeficiency Virus (HIV) Infection
On August 16, CMS published CMS Medicare Claims Processing Transmittal 3835, to remove procedure code 80081 from BR 9980.17 so that the MCSDT screen will mirror the PRVN HIMR screen. This transmittal rescinds and replaces Transmittal 3778, published May 24, 2017. All other information remains the same.
CMS published related MLN Matters 9980 on August 17.
Effective date: April 13, 2015
Implementation dates: October 2, 2017
Brooklyn Chiropractor Received Unallowable Medicare Payments for Chiropractic Services
On August 18, the OIG published a report that a Brooklyn chiropractor received at least $672,000 over two years for chiropractic services that were not allowable in accordance with Medicare requirements.
Implementation of Section 1557 for Medicare Redetermination Notices (MRNs) by Adding a Notice and Tagline Sheet
On August 18, CMS published CMS One-Time Notification Transmittal 1909, which rescinds and replaces Transmittal 1839, issued on April 28. This corrects a translation error in the Notice and Taglines attachment.
Effective date: October 1, 2017
Implementation dates: October 2, 2017
Guidance on Implementing System Edits for Certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
On August 18, CMS published CMS One-Time Notification Transmittal 1910, which rescinds and replaces Transmittal 1797, issued on February 10, 2017 to establish and implement edits that will auto deny claims paid for HCPCs codes unless the DMEPOS supplier has been identified as accredited and verified on their CMS-855S or the DMEPOS supplier is currently exempt from meeting the accreditation requirements. This changes the July implementation date and revises requirements 9904.12 and 9904.24. All other information remains the same.
Effective date: July 1, 2017
Implementation dates: July 3, 2017-- Analysis
October 2, 2017-- Coding, Testing, and Implementation
Claim Status Category and Claim Status Codes Update
On August 18, CMS published Medicare Claims Processing Transmittal 3839, which updates, as needed, the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee (ASC) X12
276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transactions.
Effective date: January 1, 2018
Implementation dates: January 2, 2018
Influenza Vaccine Payment Allowances - Annual Update for 2017-2018 Season
On August 18, CMS published Medicare Claims Processing Transmittal 3837, a recurring update notification provides the availability of payment allowances for the following seasonal influenza virus vaccines as updated on an annual basis effective August 1 of each year.
Effective date: August 1, 2017
Implementation dates: No later than October 2. 2017
Home Health Value-Based Purchasing
On August 18, CMS published Medicare Claims Processing Transmittal 3836, which directs Medicare contractors to make changes needed to support the implementation of the Home Health Value-Based Purchasing project. It also includes edits to its Provider-Specific File.
Effective date: November 21, 2017
Implementation dates: November 21, 2017
Provider Error Rate Formula
On August 18, CMS published Medicare Program Integrity Transmittal 738, which states that moving forward, Medicare Administrative Contractors (MAC) should include claims denied due to no response to additional documentation requests (ADR) when calculating the provider error rate. This is intended to assist MACs and others in deciding how to address errors, problems, and so on.
Effective date: September 19, 2017
Implementation dates: September 19, 2017
Affordable Care Act Bundled Payments for Care Improvement Initiative - Recurring File Updates Models 2 and 4 January 2018 Updates
On August 18, CMS published Medicare General Information, Eligibility, and Entitlement Transmittal 107, which serves to update the participating hospital files, episodes, and prospective bundled payment amounts associated with the Bundled Payments for Care Improvement initiative, Model 2 and Model 4.
Effective date: January 1, 2018
Implementation dates: January 2, 2018
2018 Healthcare Common Procedure Coding System (HCPCS) Annual Update Reminder
On August 18, CMS published Medicare Claims Processing Transmittal 3843, announcing that the complete HCPCS file is updated and released annually to the Medicare contractors. The file contains existing, new, revised and discontinued HCPCS codes for 2018. Contractors must download the file via the CMS mainframe in November.
Effective date: January 1, 2018
Implementation dates: January 2, 2018
Healthcare Provider Taxonomy Codes (HPTC) October 2017 Code Set Update
On August 18, CMS published Medicare Claims Processing Transmittal 3842. Medicare contractors who are affected by this update shall obtain the most recent HPTCs code set and use it to update their internal HPTC tables and/or reference files.
Effective date: October 1, 2017
Implementation dates: January 2, 2018- Contractors with the capability to do so shall implement this CR effective October 1, 2017.
Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): CORE 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE)
On August 18, CMS published Medicare Claims Processing Transmittal 3841. This transmittal instructs the contractors and Shared System Maintainers (SSMs) to update systems based on the CORE 360 Uniform Use of CARC, RARC and CAGC Rule publication. These system updates are based on the CORE Code Combination List to be published on or about October 1, 2017.
Effective date: January 1, 2018
Implementation dates: January 2, 2018