This week in Medicare updates—11/4/2020
Updated OIG Work Plan
On October 26, the OIG updated its Work Plan with the following new item:
Medicare Wellness Visits
On October 26, CMS published an MLN Educational Tool regarding the various types of Medicare wellness visits. The guide shows what is covered by Medicare, what the patient payment responsibility is, the various components of each visit, coding and billing information, and more.
Penalty for Delayed Request for Anticipated Payment (RAP) Submission--Implementation
On October 27, CMS published Medicare Claims Processing Transmittal 10403, which rescinds and replaces Transmittal 10369, dated September 24, 2020, to add business requirements 11855.15 and 11855.16, which prevent out-of-balance problems on the remittance advice and Coordination of Benefits (COB) outbound claim transaction. The original transmittal was issued regarding implementation of policies for the Home Health Prospective Payment System related to RAPS.
CMS revised MLN Matters 11855 on the same date to accompany the transmittal.
Effective date: January 1, 2021
Implementation date: January 4, 2021
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - October 2020 Update
On October 27, CMS published Medicare Claims Processing Transmittal 10408, which rescinds and replaces Transmittal 10288, dated August 7, 2020, to add a new business requirement for new CPT code 99072, and to update the attachment with additional information. The original transmittal was issued regarding the October update to the MPFSDB.
CMS revised MLN Matters 11939 on the same date to accompany the transmittal.
Effective date: January 1, 2020
Implementation date: October 5, 2020
October Quarterly Update for 2020 DMEPOS Fee Schedule
On October 27, CMS published Medicare Claims Processing Transmittal 10410, which rescinds and replaces Transmittal 10334, dated August 28, 2020, to correct BR 11956.3, to clarify the claims processing jurisdiction for code K1009, and to specify the appropriate MAC after each CWF category code. The original transmittal was issued regarding the quarterly update to the DMEPOS fee schedule.
CMS revised MLN Matters 11956 on the same date to accompany the transmittal.
Effective date: October 1, 2020
Implementation date: October 5, 2020
Proposed Rule: DMEPOS Policy Issues and Level II of the HCPCS
On October 27, CMS published a draft copy of a Proposed Rule regarding various changes to DMEPOS coverage policies and fee schedule methodologies. The rule proposes codifying sub-regulatory guidance that would streamline approval for coverage and payment of new technologies and would shorten the timeframe for making benefit classifications, pricing determinations, and billing code creation from 18 months down to six months. The rule also proposes expanded coverage for continuous glucose monitors (which would all be covered as DME) and external infusion pumps (which would be classified as DME in instances where assistance from a skilled home infusion supplier is necessary).
Comments on the rule are due 60 days after the rule’s publication in the Federal Register, which is currently scheduled for November 4. CMS published a Press Release and Fact Sheet on the rule on the same date.
Comment Request: Medical Necessity and Claims Denial Disclosures Under MHPAEA; more
On October 28, CMS published a Comment Request in the Federal Register regarding the following information collections:
- Medical Necessity and Claims Denial Disclosures Under MHPAEA
- Data Collection and Submission, Registration, Attestation, Dispute and Resolution, Record Retention, and Assumptions Document Submission, for Open Payments
Comments are due by December 28.
Comment Request: Appropriate Use Criteria for Advanced Diagnostic Imaging Services; Generic Social Marketing & Consumer Testing Research
On October 28, CMS published a Comment Request in the Federal Register regarding the submission for OMB review of the following information collections:
- Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging Services
- Generic Social Marketing & Consumer Testing Research
Comments are due to the OMB desk officer by November 27.
Fourth COVID-19 Interim Final Rule With Comment Period
On October 28, CMS published a draft copy of an Interim Final Rule with Comment on additional policy and regulatory revisions in response to the COVID-19 PHE. This IFC establishes a reimbursement rate under Part B for a potential COVID-19 vaccine at $28.39 for a single dose or, in the case of a multi-dose vaccine, $16.94 for the initial dose(s) and $28.39 for the final dose in the series. HHS will also require Medicare, Medicare Advantage, Medicaid, and many private plans to waive cost-sharing for an approved vaccine. HHS will reimburse providers who administer the vaccine to uninsured patients via the Provider Relief Fund. CMS has created an entire webpage devoted to information on the COVID-19 vaccine.
In addition to vaccine information, the rule establishes enhanced payments for new COVID-19 treatments in both the inpatient and outpatient setting. It also requires providers who perform one or more COVID-19 diagnostic tests to publicize cash prices for those tests during the PHE, and it extends the end date for the Comprehensive Care for Joint Replacement model.
CMS published a Fact Sheet, Special Edition MLN Connects article, and Press Release on the same date. Comments are due 60 days after publication of the rule in the Federal Register. The effective date will be published when the rule is published in the Federal Register.
Provider Q&A on COVID-19 Counseling
On October 28, CMS updated a Provider Q&A regarding reimbursement and billing for counseling patients on the importance of self-isolation following COVID-19 testing and on contact tracing. The document describes which settings this counseling can be provided in, how to find information on coding for this service, and why contact tracing is important.
Medicare Accelerated and Advance Payments Program COVID-19 PHE Payment Data
On October 29, CMS published a Document containing over 1600 pages of data on the accelerated and advanced payments provided during the COVID-19 PHE through October 22. The documents contain a summary of payments by program and the impact on the Medicare trust fund, payments made by provider and supplier type, and a listing of all provider and suppliers by name who received payments as well as the amount they received through the program.
CMS Refunds Withheld Funds Designated for the FDNY World Trade Center Health Program
On October 29, CMS published a News Alert regarding refunds issued to the FDNY. CMS refunded the FDNY $3.3 million on October 28 for funds that the government had withheld from the World Trade Center Health Program due to an ongoing fight with the City of New York over the city’s failure to pay Medicare for unrelated Medicare debts owed to the federal government. Although CMS acknowledged that it is no longer allowed to withhold payments to the World Trade Center Health Program as a way to satisfy New York City’s federal debts, CMS said it is working with the Treasury Department to find other ways to hold New York City responsible for debt delinquency.
Final Rule: Transparency in Coverage
On October 29, CMS published a draft copy of a Final Rule regarding requirements for group health plans and health insurance issuers to disclose cost-sharing information to participants, beneficiaries, and enrollees. Plans and issuers are required to publish three separate machine-readable files which include pricing information such as negotiated rates for all covered items services, historical payments to and billed charges from out-of-network providers, and in-network negotiated rates and historical net prices for all covered prescription drugs by plan or issuer at the pharmacy location level. These files must be made public for plan years beginning on or after January 1, 2022.
HHS will also require plans to provide an internet based self-service tool (and in paper form if requested) for participants, beneficiaries, and enrollees in order to allow people to request and receive personalized out-of-pocket cost information and underlying negotiated rates for all covered health care items and services. This will be required for an initial list of 500 shoppable services for plan years beginning on or after January 1, 2023, and it will be required for the remaining items and services for plan years beginning on or after January 1, 2024.
CMS published a Press Release and Fact Sheet on the rule on the same date. An effective date will be established once the rule is published in the Federal Register.
CY 2021 Home Health Prospective Payment System Final Rule
On October 29, CMS published a draft version of the CY 2021 Home Health PPS final rule, which is scheduled to be published in the Federal Register on November 4. CMS will increase payments to HHAs by 1.9% for CY 2021, adopts new OMB statistical area delineations, and finalizes a 5% cap on wage index decreases. In addition to regular payment rate and wage index updates, CMS finalized permanent regulatory changes to telecommunication technology use for the provision of home health services. These changes are born out of the regulatory flexibilities granted during the COVID-19 PHE, and they will allow for utilization of telecommunications systems or audio-only technology as long as it is included in the plan of care and is tied to patient-specific needs identified in the comprehensive assessment. CMS states documentation in the medical record should explain how these services will help facilitate treatment outcomes. CMS also finalized policies for the Home Health Value-Based Purchasing Model published in the May 8, 2020 IFC.
CMS published a Fact Sheet on the rule on the same date. These regulations are effective January 1, 2021.
CMS Advances Seven Finalists in Artificial Intelligence Health Outcomes Challenge
On October 29, CMS published a Press Release regarding an announcement on the seven finalists who will advance to the final round of the Artificial Intelligence Health Outcomes Challenge. In this round, the finalists will further develop algorithms which demonstrate how AI tools can be used to predict unplanned hospital and skilled nursing facility admissions an adverses events as well as a standard target to be selected by CMS. The list of the finalists is included in the press release.
Comment Request: Identification of Extension Units of Medicare Approved Outpatient Physical Therapy/Outpatient Speech Pathology Providers and Supporting Regulations
On October 30, CMS published a Comment Request in the Federal Register regarding an information collection titled “Identification of Extension Units of Medicare Approved Outpatient Physical Therapy/Outpatient Speech Pathology (OPT/OSP) Providers and Supporting Regulations.”
Comments are due by December 29.
ESRD Treatment Choices (ETC) Model Implementation: Home Dialysis Payment Adjustment (HDPA) & Waiver of the Kidney Disease Education (KDE) Benefit
On October 30, CMS published One-Time Notification Transmittal 10430 regarding implementation of the ETC Model beginning January 1, 2021. The transmittal notifies the MACs and all stakeholders about the release of the final rule, updates any previous business requirements based on provisions established by the final rule, and reminds MACs to perform any set up and testing ahead of the model’s start date in January.
Effective date: January 1, 2021
Implementation date: January 4, 2021
Primary Care First (PCF) and Serious Illness Patient (SIP) Models: Part 3: IURs and Edits for Non-Sequential Claims
On October 30, CMS published Demonstrations Transmittal 10415 in preparation for the implementation of the PCF and SIP Models. This transmittal addresses processing certain HCPCS codes under fee-for-service rules for SIP beneficiaries when there is no paid claim line of HCPCS code G2020 and how to reprocess certain previously processed HCPCS codes as flat visit fee claims with demonstration code 96.
Effective date: April 1, 2021
Implementation date: April 5, 2021
Quarterly Update to Home Health (HH) Grouper
On October 30, CMS published Medicare Claims Processing Transmittal 10433 regarding an update to the HH Grouper software to reflect new COVID-related diagnosis code changes.
Effective date: January 1, 2021
Implementation date: January 4, 2021
Internet Only Manual Update, Pub. 100-04, Chapter 11
On October 30, CMS published Medicare Claims Processing Transmittal 10407 regarding updates to manual language pertaining to notice of termination/revocation for hospice discharges, valid discharge status codes for hospice, and more. The change request rescinds and replaces change request 11807, which had been issued in June 2020.
Effective date: September 7, 2020
Implementation date: December 1, 2020
Special Provisions for Radiology Additional Documentation Requests
On October 30, CMS published One-Time Notification Transmittal 10412 regarding a process in which MACs can receive pertinent documentation from a treating/ordering practitioner during medical review to support medical necessity and payment for radiology services. This is an attempt to solve an issue where there are instances when a radiology service provider selected for review is unable to acquire supporting documentation because it would be retained by the treating/ordering practitioner.
CMS published MLN Matters 11659 on the same date to accompany the transmittal.
Effective date: December 1, 2020
Implementation date: December 1, 2020
Update to Chapter 10 of Pub. 100-08 - Enrollment Policies for Home Infusion Therapy (HIT) Suppliers
On October 30, CMS published Medicare Program Integrity Transmittal 10434 regarding the policies and procedures for enrolling HIT suppliers in Medicare. MACs begin to accept enrollment applications beginning on November 1. Payments will begin for dates of service on or after January 1, 2021.
CMS published MLN Matters 11954 on the same date to accompany the transmittal.
Effective date: January 1, 2021
Implementation date: November 1, 2020
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCD) -- April 2021
On October 30, CMS published One-Time Notification Transmittal 10432 regarding the regular coding updates specific to NCDs.
Effective date: April 1, 2021 - or as specified in individual business requirements
Implementation date: December 16, 2020, MACs; April 5, 2021 - Shared System Maintainers
Processing of Multiple Unsolicited Responses on the Same Home Health Claims
On October 30, CMS published One-Time Notification Transmittal 10429 regarding an update to the Medicare systems to allow it to apply multiple unsolicited responses on the same home health claim. This issue arose because the Patient-Driven Groupings Model can now cause a claim to be identified for adjustment by an inpatient stay IUR and an A-B shift UR in the same processing cycle in rare instances.
Effective date: January 1, 2020
Implementation date: April 5, 2021
Send Electronic Funds Transfer (EFT) Information from PECOS to MCS Phase 2
On October 30, CMS published One-Time Notification Transmittal 10422 regarding implementation of the two-phased approach in which CMS is reducing the two-day cycle for MCS claims processing when data is received from PECOS and the NPI appears on the Master Provider File.
Effective date: April 1, 2021
Implementation date: April 5, 2021
CY 2022 Medicare Advantage and Part D Advance Notice Part II
On October 30, CMS published Part II of the CY 2022 Medicare Advantage and Part D Advance Notice as well as a Fact Sheet and Press Release on the notice. The proposed changes listed in Part II of the Advance Notice include using encounter data as the sole source of diagnoses used to calculate Medicare Advantage risk scores, applying a coding pattern adjustment of 5.9% for CY 2022, implementing an updated version of the RxHCC risk adjustment model for adjusting direct subsidy payments for Part D benefits and Medicare Advantage prescription drug plans, and more. CMS is also soliciting feedback on including a potential COVID-19 vaccination measure for the 2023 Part C&D performance measures as a way to encourage health plans to play a role in educating and encouraging their members to get the vaccine.
CMS is publishing the Advance Notice approximately three months early to provide Medicare Advantage organizations and Part D sponsors more time to consider information before making bids for 2022. Comments on both Part I and Part II of the Advance Notice are due by November 30, 2020. The finalized 2022 rate announcement is scheduled to be published no later than April 5, 2021.
New Nursing Home Resource Center Website
On October 30, CMS published a Press Release to announce it has created a new Nursing Home Resource Center website to serve as a single, centralized location which gathers all information specific to nursing homes. The website will remain active through and beyond the COVID-19 PHE.