This week in Medicare updates—8/18/2021
New Waived Tests
On August 6, CMS published Medicare Claims Processing Transmittal 10897 regarding newly waived CLIA tests. There are six new tests in this version of updates.
CMS published MLN Matters 12381 on the same date to accompany the transmittal.
Effective date: October 1, 2021
Implementation date: October 4, 2021
Update of Internet Only Manual, Pub. 100-04, Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician Supplier Claims
On August 6, CMS published Medicare Claims Processing Transmittal 10640 regarding updates to the manual to incorporate ESRD and acute kidney injury policies that had been established through prior communications. These include payment limits, use of modifier -CG, payment for dialysis for AKI patients at ESRD facilities, and more.
CMS published MLN Matters 12079 on the same date to accompany the transmittal.
Effective date: September 7, 2021
Implementation date: September 7, 2021
Revisions to Chapters 13 and 32 to Update Coding
On August 6, CMS published Medicare Claims Processing Transmittal 10881 regarding updates to the manual to incorporate new codes under various NCDs. These include CPT codes for PET scans, diagnosis codes for home INR monitoring, and more.
Effective date: September 7, 2021, from issuance
Implementation date: September 7, 2021, from issuance
Internet Only Manual Updates to Pub. 100-01, 100-02, and 100-04 to Implement Consolidated Appropriations Act Changes and Correct Errors and Omissions (SNF)
On August 6, CMS published Medicare General Information, Eligibility, and Entitlement Transmittal 10880, Medicare Benefit Policy Transmittal 10880, and Medicare Claims Processing Transmittal 10880 regarding updates to the manuals to correct some technical errors and omissions and to reflect provisions of the Consolidated Appropriations Act of 2021 as it applies to SNFs.
CMS published MLN Matters 12009 on the same date to accompany the transmittals.
Effective date: November 8, 2021
Implementation date: November 8, 2021
Medicare Continues to Make Overpayments for Chronic Care Management Services
On August 9, the OIG published a Review of whether CMS payments to providers for noncomplex and complex chronic care management (CCM) services during CYs 2017 and 2018 compiled with federal requirements. Of the over 8 million claims reviewed by the OIG, 50,192 claims did not comply with federal requirements, resulting in just over $1.9 million in overpayments and $540,680 in beneficiary cost-sharing. Most issues (38,447 claims) were found in instances where providers billed noncomplex or complex CCM services more than once for the same beneficiary in the same service period. Other issues included instances (10,882 claims) when the same provider billed for both noncomplex or complex CCM services and overlapping care management services rendered to the same beneficiary in the same service period as well as instances (863 claims) in which incremental complex CCM services were billed along with complex CCM services identified as overpayments. The OIG said these errors occurred because CMS did not have claim system edits to prevent and detect overpayments.
The OIG recommends CMS direct the contractors to recover the $1.9 million for claims within the reopening period and refund up to $540,680 in cost-sharing that beneficiaries were required to pay. It also recommends CMS implement claim system edits to prevent and detect overpayments for these services and notify providers so they can identify, report, and return any overpayments in accordance with the 60-day rule. CMS concurred with the recommendations but raised concern about whether providers are liable for the overpayments because they may be found to be without fault under the Social Security Act.
Implementation of the GV Modifier for Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) for Billing Hospice Attending Physician Services
On August 10, CMS published Medicare Claims Processing Transmittal 10907 regarding implementation of the GV modifier for RHCs and FQHCs to report when billing for hospice attending physician services furnished by certain RHC or FQHC practitioners during a patient’s hospice election.
CMS published MLN Matters 12357 on the same date to accompany the transmittal.
Effective date: January 1, 2022
Implementation date: January 3, 2022
Waiver of Coinsurance and Deductible for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)
On August 10, CMS published Medicare Claims Processing Transmittal 10906 to fix an issue where coinsurance was not being waived for screening for lung cancer with LDCT on TOB 085X and non-OPPS claims. This transmittal instructs contractors to properly waive the coinsurance and deductible for HCPCS code 71271 on those TOBs and professional claims.
Effective date: January 1, 2022 - For claims with dates of service on and after January 1, 2021
Implementation date: January 3, 2022
CMS Rescinds Most Favored Nation (MFN) Model
On August 10, CMS published a Proposed Rule in the Federal Register to rescind the MFN Model interim final rule, which was published in the Federal Register on November 27, 2020. The rule was supposed to have gone into effect January 1, 2021, but it was never implemented due to a nationwide preliminary injunction issued by the U.S. District Court for the Northern District of California on December 28, 2020. Multiple lawsuits against the rule resulted in the courts finding numerous procedural issues with the MFN Model, and CMS said those issues combined with concerns from stakeholders about the rule led CMS to propose to rescind the rule. CMS said it continues to look for ways to address the rising costs of Part B drugs and will consider comments on the interim final rule as well as comments on this proposal as it explores other options for incorporating value into payments for Part B drugs and improving beneficiary access to care.
Comments on the proposed rule are due by October 12.
Updated List of Excluded Individuals and Entities (LEIE)
On August 10, the OIG updated its LEIE with an updated LEIE database for download and lists of July 2021 exclusions, reinstatements, and profile corrections.
Updated Provider Self-Disclosure Settlements and Affirmative Exclusions
On August 10, the OIG published an updated List of Provider Self-Disclosure Settlements and Affirmative Exclusions with the following organizations:
- On July 1, Sentara Healthcare, of Virginia, reached a $4,330,218 settlement with the OIG after self-disclosing that it submitted or caused the submission of improper claims for observation services provided to patients discharged from the emergency departments.
- On July 13, Dr. David Kaner and Kaner Medical Group, of Texas, reached a $94,440 settlement with the OIG to resolve allegations that it solicited and received remuneration from the laboratory company Health Diagnostic Laboratory in the form of “process and handling” payments related to the collection of blood.
- On July 14, Northwest Community Home Healthcare, of Illinois, reached a $95,667.35 settlement with the OIG after self-disclosing that it submitted false claims for skilled nursing home health services provided by a former employee that should have been billed at lower rates or not billed at all.
- On July 21, CarePlus Emergency Ambulance Service, of New Hampshire, reached a $200,000 settlement with the OIG to resolve allegations that it presented claims to Part B for ambulance transportation to and from SNFs when the transport was already covered by SNF consolidated billing under Part A.
- On July 30, Marywood Nursing Care Center, of Michigan, reached a $230,146.17 settlement with the OIG after self-disclosing that it submitted claims for services provided by an unlicensed nurse.
Medicare Billing for COVID-19 Vaccine Shot, Monoclonal Antibody Infusions
On August 11, CMS updated its Billing for COVID-19 Vaccine Shot Administration and Monoclonal Antibody COVID-19 Infusion webpages. Because CMS does not indicate which information is new, it is best to review the page and associated links in their entirety.
Medicare Updates for COVID-19 Booster Shots
On August 12, CMS updated its COVID-19 Vaccines and Monoclonal Antibodies webpage with revised download links for Fact Sheets and EUAs for the Moderna and Pfizer COVID-19 vaccines. The revisions note that third shots may be administered at least 28 days following the first two doses of the vaccine in individuals 12 years of age or older who have undergone solid organ transplants or have an equivalent level of immunocompromisation.
On August 13, CMS published a Press Release to announce that this additional dose of the COVID-19 vaccine in immunocompromised Medicare beneficiaries will be provided with no cost-sharing. CMS said it will share more information about billing and coding for the booster shot in the coming days.
Concerns Persist About Opioid Overdoses and Medicare Beneficiaries’ Access to Treatment and Overdose-Reversal Drugs
On August 12, the OIG published a Review regarding opioid use, medication-assisted treatment (MAT) drugs, and naloxone in Part D in 2020. The OIG found that more than 43,000 Part D beneficiaries suffered an opioid overdose in 2020, but that number should likely be higher as additional beneficiaries may have suffered an overdose without receiving medical care billed to Medicare. Nearly 1 in 4 Part D beneficiaries received opioids in 2020, but the number of beneficiaries receiving short-term opioid prescriptions dropped sharply in the early months of the pandemic. The number of beneficiaries receiving MAT drugs increased at a slower rate in 2020 than in other years, and there was no growth in 2020 in the number of beneficiaries receiving prescriptions for naloxone--a stark difference from recent years. The OIG said these reduced growth rates add to concerns about access to MAT drugs and naloxone.
The OIG continues to encourage CMS to educate beneficiaries and providers about access to MAT drugs and naloxone. It also encourages CMS to closely monitor the number of beneficiaries receiving MAT drugs and naloxone and take action if needed.
Removal of Provider Enrollment Policy from Chapter 15 in Pub. 100-08
On August 12, CMS published Medicare Program Integrity Transmittal 10945 regarding the removal of all remaining policy from Chapter 15 of the manual due to the ongoing reorganization involving moving Chapter 15 information to Chapter 10.
Effective date: September 13, 2021
Implementation date: September 13, 2021
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for FY 2022
On August 12, CMS published Medicare Claims Processing Transmittal 10944 regarding changes required due to payment updates and policies finalized in the FY 2022 IPF PPS final rule.
CMS published MLN Matters 12417 on the same date to accompany the transmittal.
Effective date: October 1, 2021
Implementation date: October 4, 2021
Comment Request: Request for Certification as Supplier of Portable X-Ray Services under the Medicare/Medicaid Program; Request for Certification in the Medicare/Medicaid Program for Providers of Outpatient Physical Therapy and/or Speech Language Pathology
On August 13, CMS published a Comment Request in the Federal Register regarding the submission of the following information collections for OMB review:
- Request for Certification as Supplier of Portable X-Ray Services under the Medicare/Medicaid Program
- Request for Certification in the Medicare/Medicaid Program for Providers of Outpatient Physical Therapy and/or Speech Language Pathology
Comments are due to the OMB desk officer by September 13.