This week in Medicare updates—3/3/2021
COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers
On February 19, CMS updated the blanket waivers for health care providers Fact Sheet regarding modifications to the Condition of Participation for nursing services (§482.23) to add language for COVID-19 vaccines approved by the FDA or authorized under an EUA. This allows nurses to administer the vaccine without requiring an order that is documented and signed by a practitioner.
CMS continues to update this document, and organizations should review regularly for any changes.
Acute Hospital Care At Home Approved List
On February 19, CMS updated a List of approved hospitals participating in the Acute Care Hospital at Home program as of February 19, 2021. The program expanded to include a total of 103 hospitals across 44 systems in 28 states.
CMS updated an FAQ on the program on the same date. CMS did not mark which items in the FAQ are new.
COVID-19 FAQs on Medicare Fee-for-Service Billing
On February 19, CMS updated an FAQ regarding the latest guidance on billing for COVID-19. This round of updates included guidance per provider type on billing for COVID-19 monoclonal antibody products and their infusion, information on whether Medicare will require orders from physicians/non-physician practitioners for a COVID-19 vaccine or monoclonal antibodies, and guidance on billing for ASCs that are temporarily enrolling as a hospital during the PHE.
CMS continues to update this document on a regular basis. Providers should review frequently for new information.
Noridian Made Improper Medicare Payments to Physicians in Jurisdiction E for Spinal Facet Joint-Injections
On February 22, the OIG published a Review of whether Noridian paid physicians in Jurisdiction E for spinal facet-joint injections in accordance with Medicare requirements. The OIG found that Noridian made improper payments to physicians in Jurisdiction E for 51 of the 100 beneficiary days included in the sample. The OIG said this occurred because Noridian did not provide sufficient education for physicians and billing staff to ensure that physicians were compliant with billing requirements. The OIG found that Noridian made $12,546 in improper payments for the sample and an estimated $4.2 million for all physicians within the audit period.
The OIG recommends Noridian recover the $12,546 in improper payments; notify appropriate physicians to all physicians to identify, report, and return any overpayments in accordance with the 60-day rule; and provide annual training to physicians and their billing staff in Jurisdiction E regarding Medicare requirements for billing facet-joint injections.
CMS Offers Comprehensive Support to Texas to Combat Winter Storm
On February 22, CMS published a Press Release on actions it is taking to support Texas in the wake of a severe winter storm, which was declared a public health emergency retroactive to February 11. These actions include special enrollment opportunities to allow for immediate access to healthcare, steps to ensure dialysis patients can obtain services, waivers to the 3-day prior hospitalization stay for coverage of SNF services, and more. Providers should review the press release and CMS’ new non-COVID emergency website for more details.
Review of Hospital Compliance with Medicare’s Transfer Policy with the Resumption of Home Health Services & Other Information on Patient Discharge Status Codes
On February 22, CMS published Special Edition MLN Matters 21001 regarding Medicare’s post-acute care transfer policy and proper coding of patient discharge status. It notes that several recent OIG reviews have identified overpayments to hospitals that didn’t comply with the policy, especially in terms of hospitals transferring inpatients to post-acute care settings but coding the patient discharge status as a discharge to home. The article reviews definitions and requirements for the post-acute care transfer policy and discusses the process for discharging patients either to a post-acute care setting or to the patient’s home.
Billing for Services when Medicare is a Secondary Payer
On February 23, CMS published Special Edition MLN Matters 21002 regarding an issue where CMS has inappropriately denied certain MSP claims (liability, no-fault, or worker’s compensation) when services were provided that were not related to the accident or injury. CMS instructs providers who believe they received inappropriate denials to contact the MACs to appeal claims. It also directs providers to tell beneficiaries not to call the Benefits Coordination and Recovery Center to delete the open MSP record because the record may be active and should not be deleted.
Quarterly Update for the DMEPOS Competitive Bidding Program (CBP) - April 2021
On February 23, CMS published MLN Matters 12128, which accompanies Medicare Claims Processing Transmittal 10565, dated January 20, regarding implementation of the quarterly updates to the DMEPOS CBP, which include changes to HCPCS, zip code, single payment amount, and supplier files.
Effective date: April 1, 2021
Implementation date: April 5, 2021
April 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
On February 23, CMS published MLN Matters 12133, which accompanies Medicare Claims Processing Transmittal 10562, dated January 20, regarding quarterly updates to ASP and Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs.
Effective date: April 1, 2021
Implementation date: April 5, 2021
HCPCS Codes Subject to and Excluded from CLIA Edits
On February 23, CMS published MLN Matters 12131, which accompanies Medicare Claims Processing Transmittal 10564, dated January 20, regarding new HCPCS codes for 2021 that are subject to and excluded from CLIA edits. New HCPCS codes include multiple COVID-19 related codes, liver disease tests, multiple red blood cell antigen genotyping tests, and more.
Effective date: April 1, 2021
Implementation date: April 5, 2021
Correction: CY 2021 Outpatient Prospective Payment System Final Rule
On February 23, CMS published a Correction Notice in the Federal Register regarding corrections to technical and typographical errors made in the 2021 OPPS Final Rule, which was published in the Federal Register on December 29, 2020. The errors include incorrect references to quarters for data collections, incorrect years for the application of proposed packaging statuses for drugs and biologicals, an incorrect reference to a skin substitute being assigned to a low cost group rather than a high cost group, typos on status indicators, and more.
Effective date: This correction is effective February 25, 2021.
Applicability date: The corrections in this correcting document are applicable beginning January 1, 2021.
Updated List of CMS Recognized PC IOLs and AC IOLs
On February 24, CMS published an updated List of presbyopia-correcting intraocular lenses (PC IOLs) and astigmatism-correcting IOLs (AC IOLs). The additional IOL items will follow the ruling set forth for CMS payment for the insertion of PC IOLs, AC IOLs, or both in CMS ruling 05-01 and CMS ruling 1536-R.
Trend Toward More Expensive Inpatient Hospital Stays in Medicare Emerged Before COVID-19 and Warrants Further Scrutiny
On February 24, the OIG published a Review of trends in the amount and expense of inpatient hospital stays billed at the highest MS-DRG severity level from FY 2014 through FY 2019. The OIG found that the number of stays billed at the highest severity level increased nearly 20% from 2014 through 2019 and accounted for nearly half of all Medicare spending on inpatient hospital stays. The number of stays billed at other severity levels decreased, and average length of stay for stays at the highest severity level also decreased (although average length of all stays regardless of severity level stayed the same). The OIG noted that it is concerned about upcoding and other inappropriate billing practices, especially as hospitals varied significantly in how they billed these stays.
The OIG recommends that CMS conduct targeted reviews of MS-DRGs and stays that are vulnerable to upcoding. CMS did not concur with the recommendation but said more work needs to be done to determine which changes in billing could be attributed to upcoding. The OIG responded by saying that because more work needs to be done, CMS should conduct these targeted reviews to identify stays involving upcoding.
Hospice Provider Compliance Audit: Tidewell Hospice, Inc.
On February 24, the OIG published a Review of whether hospice services provided by Tidewell Hospice complied with Medicare requirements. The OIG found that Tidewell did not comply with Medicare requirements for 18 of the 100 claims. Errors involved claims for which the clinical record did not support the beneficiary’s terminal diagnosis or the level of care claimed, and errors also involved claims for services that were not eligible for Medicare reimbursement. The OIG estimates that Tidewell received at least $8.3 million in Medicare reimbursement for noncompliant hospice services.
In response to the OIG’s draft report, Tidewell argued that all but five claims were compliant. It said the independent medical review contractor’s conclusions were either inaccurate or divergent from clinical facts present in the medical records. Tidewell also accused the independent medical review contractor of glossing over the critical role of a physician’s certification of terminal illness. After reviewing Tidewell’s comments, the OIG maintained its original findings. The OIG recommends Tidewell refund the federal government for the portion of the $8.3 million within the 4-year claims reopening period; identify, report, and return any overpayments within the 60-day rule; and strengthen its procedures to ensure hospice services comply with Medicare requirements.
FAQ: Plan and Issuer Coverage Requirements for COVID-19 Diagnostic Testing; Provider Reimbursement for COVID-19 Vaccines to Uninsured
On February 26, CMS published an FAQ providing clarification of requirements in the Families First Coronavirus Response Act and the CARES Act for health plan and insurance issuer coverage of COVID-19 diagnostic testing. The FAQ also addresses how health care providers should seek reimbursement for COVID-19 vaccine-related services provided to uninsured patients. The FAQ states that plans and issuers may not impose cost-sharing, prior authorization, or other medical management requirements for COVID-19 diagnostic testing when testing is for asymptomatic individuals with no known or suspected exposure. Exceptions apply only in limited circumstances, such as testing for employment purposes or public health surveillance.
CMS published a Press Release on the FAQ on the same date.
HHS-OIG Statement on Telehealth
On February 26, the OIG published a Statement regarding its oversight of telehealth and its potential for fraud, abuse, or misuse. The OIG stated that the nationwide increase in telehealth services during the pandemic is a mostly positive expansion, but it also noted that it is conducting significant oversight work regarding telehealth services during the PHE to help inform policymakers and other stakeholders on what telehealth flexibilities should become permanent. It also defined “telefraud” schemes, which involve telemarketing in combination with unscrupulous doctors, and said these schemes are different from telehealth fraud.
FDA Issues Emergency Use Authorization (EUA) for Janssen COVID-19 Vaccine
On February 27, the FDA issued an EUA for the Janssen (Johnson & Johnson) COVID-19 vaccine, effective immediately. CMS published coding and payment information for the vaccine on its COVID-19 Vaccines and Monoclonal Antibodies webpage on the same date. Because the Janssen vaccine is a single-dose shot, there is a one-time $28.39 payment for administration. The Moderna and Pfizer vaccines receive a $16.94 initial payment for administration of the first dose of those vaccines followed by a $28.39 payment for administration of the second dose. Providers should report CPT code 91303 for the Janssen vaccine and CPT code 0031A to report vaccine administration for the Janssen vaccine. These codes are effective February 27, 2021.