This week in Medicare updates—1/27/2021
Send Electronic Funds Transfer (EFT) Information from PECOS to MCS Phase 2
On January 5, CMS published One-Time Notification Transmittal 10551, which rescinds and replaces Transmittal 10422, dated October 30, 2020, to revise the dates in BRs 11987.5, 11987.6, and 11987.9. The original transmittal was published 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
Renewal of COVID-19 PHE
On January 7, ASPR published a Notice announcing that HHS Secretary Alex Azar has renewed the COVID-19 PHE effective January 21, 2021. This will extend the PHE and all applicable waivers tied to it for an additional 90 days.
January 2021 Update of the Ambulatory Surgical Center (ASC) Payment System
On January 8, CMS published Medicare Claims Processing Transmittal 10557, which rescinds and replaces Transmittal 10546, dated December 31, 2020, to correct Attachment B with the addition of missing existing HCPCS J0390, J0745, J2560, 0583T, and Q5118. The original transmittal was issued regarding changes to and billing instructions for various payment policies implemented in the January 2021 ASC payment system update.
On January 5, CMS published MLN Matters 12129 to accompany the transmittal.
Effective date: January 1, 2021
Implementation date: January 4, 2021
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 2nd Qtr Notification for FY 2021
On January 12, CMS published Medicare Financial Management Transmittal 10561 regarding the second quarter update to the interest rate on Medicare overpayments and underpayments. The Department of Treasury has changed the private consumer rate to 9.625%.
Effective date: January 19, 2021
Implementation date: January 19, 2021
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCD) -- April 2021
On January 14, CMS published One-Time Notification Transmittal 10566, which rescinds and replaces Transmittal 10515, dated December 10, 2020, to remove FISS Reason Codes 59041, 59402, and 59210. The original transmittal was issued regarding the regular coding updates specific to NCDs.
On January 20, CMS revised MLN Matters 12027 to accompany the transmittal.
Effective date: April 1, 2021 - or as specified in individual business requirements
Implementation date: December 16, 2020 - 45 days from issuance MACs; April 5, 2021 - Shared System Maintainers
Implementation of Changes in the End-Stage Renal Disease (ESRD) PPS and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facility for CY 2021
On January 14, CMS published Medicare Benefit Policy Transmittal 10568, which rescinds and replaces Transmittal 10490, dated November 23, 2020, to withdraw the requirement for reporting time on dialysis machine by removing the verbiage in the background and policy sections. The original transmittal was published regarding implementation of the 2021 rate updates and policies for the ESRD PPS.
On January 19, CMS revised MLN Matters 12011 to accompany the transmittal.
Effective date: January 1, 2021
Implementation date: January 4, 2021
Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) Claims
On January 14, CMS published Medicare Claims Processing Transmittal 10569, which rescinds and replaces Transmittal 10448, dated November 6, 2020, to add BR 11992.3.1. The original transmittal was published with instructions for billing claims with covered and non-covered days using occurrence span code 76.
On January 20, CMS revised MLN Matters 11992 to accompany the transmittal.
Effective date: April 1, 2021
Implementation date: April 5, 2021
April 2021 Update to the FY 2021 IPPS
On January 15, CMS published Medicare Claims Processing Transmittal 10572, which rescinds and replaces Transmittal 10496, dated November 25, 2020, to update the background section and add BRs 12062.2 and 12062.3. The original transmittal was published regarding an update to the IPPS PPS Pricer to allow for up to 10 NDCs to be passed to the IPPS PPS Pricer for payment consideration.
Effective date: April 1, 2021
Implementation date: April 5, 2021
FAQs on Market-Based MS-DRG Relative Weights
On January 15, CMS published an FAQ document regarding the market-based MS-DRG relative weight data collection policy. The FAQs explain ways hospitals can calculate and report median payer-specific negotiated charges by MS-DRG on the Medicare cost report for cost reporting periods ending on or after January 1, 2021. This is a policy that had been finalized in the 2021 IPPS final rule.
2022 Medicare Advantage and Part D Rate Announcement
On January 15, CMS published the 2022 Medicare Advantage and Part D Rate Announcement. This document has been published three months earlier than usual to provide plans more time to consider the information as they prepare to finalize their bids. CMS is completing the phase-in of the CY 2020 CMS-HCC model for risk adjustment, will rely entirely on encounter data when calculating risk scores, and will identify diagnoses through HCPCS-based filtering logic. CMS also finalized a coding pattern adjustment of 5.9% for CY 2022 and said it continues to consider ways to ease burden due to COVID-19, but it noted that any COVID-19 policy changes are out of the scope of the Rate Announcement and therefore will not be discussed within it.
CMS published a Fact Sheet and Press Release on the Rate Announcement on the same date.
FY 2021 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes
On January 16, CMS published Medicare Claims Processing Transmittal 10571, which rescinds and replaces Transmittal 10360, dated September 18, 2020, to correct a value in Section G. Updating the PSF for Wage Index, Reclassifications and Redesignations and Wage Index Changes and Issues. The original transmittal was published regarding implementation of the FY 2021 IPPS and LTCH PPS updates.
On September 22, CMS published MLN Matters 11879 to accompany the transmittal.
Effective date: October 1, 2020
Implementation date: October 5, 2020
FY 2019 Report to Congress (RTC): Review of Medicare’s Program Oversight of Accrediting Organizations (AO) and the CLIA Validation Program
On January 19, CMS published a Memorandum to state survey agency directors regarding the 2019 RTC, which discusses reviews, validation, and oversight of the FY 2018 activities of approved AOs Medicare accreditation programs as well as the CLIA validation program. The memo also notes that as part of additional oversight initiatives, CMS is posting AO performance data and complaint surveys for hospitals publicly. It is also piloting a new way to assess AOs’ ability to ensure facilities and suppliers comply with CMS requirements by eliminating the second state-conducted validation survey and using direct observation during the original AO-run survey instead to evaluate compliance with Conditions of Participation.
Effective date: Immediately. This report should be communicated with appropriate survey and certification staff, their managers, and the state/regional office training coordinators within 30 days of this memorandum.
Correction: CY 2021 Medicare Physician Fee Schedule (MPFS) Final Rule
On January 19, CMS published a Correction Notice in the Federal Register to make corrections to technical errors in the original version of the MPFS final rule, which was published on December 28, 2020. Errors include inadvertently excluded language about public comments, misidentified measure stewards, typographical errors, and more.
Dates: This correction is effective January 19, 2021, and is applicable beginning January 1, 2021.
Decision Memo for Screening for Colorectal Cancer - Blood-Based Biomarker Tests
On January 19, CMS published a Decision Memo regarding coverage for blood-based biomarker tests for colorectal cancer. CMS is approving coverage of this test once every three years as a form of cancer screening when both the test and the patient meet requirements outlined in the decision memo. However, a currently available Epi proColon ® test does not meet the criteria for an appropriate version of this test, and therefore CMS will not cover it at this time.
Decision Memo for Transcatheter Mitral Valve Repair (TMVR)
On January 19, CMS published a Decision Memo regarding expanded coverage of the transcatheter edge-to-edge repair (TEER) of the mitral valve for patients with severe functional mitral regurgitation (MR). The previous NCD covered TEER of the mitral valve only for Medicare patients with significant symptomatic degenerative MR under coverage with evidence development (CED). In addition to expanded coverage to patients with functional MR, CMS is removing the CED designation and will allow MACs discretion to cover TEER of the mitral valve for patients with degenerative MR. CMS is also replacing the term TMVR in the NCD with the term TEER to more precisely define the treatment.
CMS and Its Contractors Did Not Use Comprehensive Error Rate Testing Program Data to Identify and Focus on Error-Prone Providers
On January 19, the OIG published a Report regarding whether CMS and its contractors used CERT program data to identify and focus on error-prone providers. The OIG created the term “error-prone provider” to indicate providers who had at least one error in each of the four CERT years analyzed, and error rate higher than 25% in each of those four years, and a total error amount of at least $2500. The OIG used CERT data from 2014 through 2017 to identify 100 error-prone providers. Of the $5.8 million in payments reviewed by CERT for these providers, $3.5 million in payments were improper (an error rate of over 60%). During that same period, Medicare made $19.1 billion in FFS payments to these 100 providers.
The OIG recommends CMS review the list of error-prone providers and take specific action as appropriate (such as requiring prior authorizations, prepayment reviews, and postpayment reviews). It also recommends CMS use CERT data to identify individual providers that have an increased risk of receiving improper payments and apply additional program integrity tools to these providers. CMS did not concur with the recommendations, as it disagreed with the methodology for identifying error-prone providers. It also stated that it previously tried to use CERT data to identify error-prone providers, but it found CERT data was ineffective and therefore discontinued the practice of identifying these providers. The OIG maintained that its findings and recommendations are valid and CMS can improve its ability to detect these types of providers.
CY 2022 Part D Payment Modernization Model Changes
On January 19, CMS published a Fact Sheet regarding changes and a request for applications for the Part D Payment Modernization Model. The model, which was launched last January, tests the impact of a revised Part D program design and incentive alignment on overall prescription drug spending and beneficiary out-of-pocket costs. For CY 2022, CMS is allowing Part D sponsors to make use of additional programmatic tools to better manage drug spending, increase engagement, and promote enrollee understanding of their Part D benefit. CMS also will not apply the 10% downside model risk for Part D sponsors participating in the model in CY 2022.
Part D sponsors who are interested in participating in 2022 must submit a non-binding Notice of Intent (NOI) by March 1, 2021. More information is available on the model website.
Hospital Survey Priorities
On January 20, CMS published a Memorandum to state survey agency directors regarding hospital survey and oversight expectations during the COVID-19 PHE. In order to ensure quality of care oversight while still allowing hospitals to focus on caring for COVID-19 patients during recent surges in hospitalizations, CMS is issuing limitations on certain hospital surveys for 30 days after the issuance of the memo. Hospital complaint surveys will be restricted to immediate jeopardy complaint allegations, hospital recertification surveys will be suspended (except for a subset of accreditation surveys), and hospital enforcement actions for deficiencies that do not represent immediate jeopardy will have their termination dates extended for at least 30 days. More details in how these specific surveys will be conducted is included in the memo.
Effective date: Immediately. This policy should be communicated to all survey and certification staff and managers immediately.
April 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
On January 20, CMS published Medicare Claims Processing Transmittal 10562 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 January 20, CMS published Medicare Claims Processing Transmittal 10564 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
Second Update to Policies on Enrollment of Opioid Treatment Programs (OTP)
On January 20, CMS published Medicare Program Integrity Transmittal 10560 regarding the addition of additional policies and clarifications into the manual concerning the enrollment of OTPs in Medicare and information on processing Form CMS-855B attachments pertaining to prescribing, ordering, and dispensing OTP personnel.
Effective date: January 4, 2021
Implementation date: January 29, 2021
Update to Chapter 12 (The Comprehensive Error Rate Testing [CERT] Program) of Pub. 100-08
On January 20, CMS published Medicare Program Integrity Transmittal 10567 regarding changes to the manual to note that the new website the CERT program will be using will be called the C3HUB. The website will replace the current Claims Status website effective January 18, 2021. The transmittal also discusses changes to claim feedback procedures as a result of the new website.
Effective date: January 18, 2021
Implementation date: January 29, 2021
Primary Care First (PCF) and Serious Illness Patient (SIP) Models: Part 2: FFS Payments and Other Claims-Based Adjustments
On January 20, CMS published Demonstrations Transmittal 10577, which rescinds and replaces Transmittal 10537, dated December 30, 2020, to add new HCPCS codes to appendices A and B. The original transmittal was issued regarding implementation of certain components of the PCF and SIP Models for the January 2021 release.
Effective date: January 1, 2021 - Applicable to the PCF component (excludes beneficiaries and providers from the SIP component); April 1, 2021 - Applicable to the SIP component
Implementation date: January 4, 2021
Changes to the ESRD PRICER to Accept the New Outpatient Provider Specific File Supplemental Wage Index Fields, the Network Reduction Calculation and New Value Code for Time on Machine
On January 20, CMS published One-Time Notification Transmittal 10576, which rescinds and replaces Transmittal 10368, dated September 24, 2020, to withdraw the requirement for reporting time on dialysis machine instructed in BRs 11871.7 and 11871.1 by removing the verbiage in the background and policy sections. This transmittal is no longer sensitive and is now being posted to the internet. The original transmittal was issued regarding the implementation of new supplemental wage index fields and a new value code in the ESRD PRICER.
On January 20, CMS published MLN Matters 11871 to accompany the transmittal.
Effective date: January 1, 2021
Implementation date: January 4, 2021
CY 2021 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
On January 20, CMS published Medicare Claims Processing Transmittal 10575, which rescinds and replaces Transmittal 10523, dated December 18, 2020, to correct the payment determination for code 0177U crosswalk from 81310 to 81309 in the attachment. The original transmittal was issued regarding the CY 2021 update to the CLFS.
CMS revised MLN Matters 12080 on the same date to accompany the transmittal.
Effective date: January 1, 2021
Implementation date: January 4, 2021
Quarterly Update for the DMEPOS Competitive Bidding Program (CBP) - April 2021
On January 20, CMS published Medicare Claims Processing Transmittal 10565 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
Modernization of the Electronic Files Transfer (EFT) Associated with the National Coordination of Benefits Agreement (COBA) Crossover Process
On January 20, CMS published Medicare Claims Processing Transmittal 10559 regarding new file dataset names that the Virtual Data Centers and associated MACs should use when transmitting and receiving COBA-related files from the Coordination of Benefits & Recovery (COB&R) systems hub.
Effective date: April 5, 2021
Implementation date: April 5, 2021