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Friday, December 27, 2013
President Obama Signs the Pathway for SGR Reform Act of 2013
--New Law Includes Physician Update Fix through March 2014--
On December 26, 2013, President Obama signed into law the Pathway for SGR Reform Act of 2013. This new law prevents a scheduled payment reduction for physicians and other practitioners who treat Medicare patients from taking effect on January 1, 2014. The new law provides for a 0.5 percent update for such services through March 31, 2014. President Obama remains committed to a permanent solution to eliminating the Sustainable Growth Rate (SGR) reductions that result from the existing statutory methodology. The Administration will continue to work with Congress to achieve this goal.
The new law extends several provisions of the Middle Class Tax Relief and Job Creation Act of 2012 (Job Creation Act) as well as provisions of theAffordable Care Act. Specifically, the following Medicare fee-for-service policies have been extended. We also have included Medicare billing and claims processing information associated with the new legislation. Please note that these provisions do not reflect all of the Medicare provisions in the new law, and more information about other provisions will be forthcoming.
Section 1101 – Medicare Physician Payment Update – As indicated above, the new law provides for a 0.5 percent update for claims with dates of service on or after January 1, 2014, through March 31, 2014. CMS is currently revising the 2014 Medicare Physician Fee Schedule (MPFS) to reflect the new law’s requirements as well as technical corrections identified since publication of the final rule in November. For your information, the 2014 conversion factor is $35.8228.
Section 1102 - Extension of Medicare Physician Work Geographic Adjustment Floor - The existing 1.0 floor on the physician work geographic practice cost index is extended through March 31, 2014. As with the physician payment update, this extension will be reflected in the revised 2014 MPFS.
Section 1103 - Extension Related to Payments for Medicare Outpatient Therapy Services - Section 1103 extends the exceptions process for outpatient therapy caps through March 31, 2014. Providers of outpatient therapy services are required to submit the KX modifier on their therapy claims, when an exception to the cap is requested for medically necessary services furnished through March 31, 2014. In addition, the new law extends the application of the cap and threshold to therapy services furnished in a hospital outpatient department (OPD). Additional information about the exception process for therapy services may be found in the Medicare Claims Processing Manual, Pub.100-04, Chapter 5, Section 10.3.
The therapy caps are determined for a beneficiary on a calendar year basis, so all beneficiaries began a new cap for outpatient therapy services received onJanuary 1, 2014. For physical therapy and speech language pathology services combined, the 2014 limit for a beneficiary on incurred expenses is $1,920. There is a separate cap for occupational therapy services which is $1,920 for 2014. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached, and also apply for services above the cap where the KX modifier is used.
Section 1103 also extends the mandate that Medicare perform manual medical review of therapy services furnished January 1, 2014 through March 31, 2014, for which an exception was requested when the beneficiary has reached a dollar aggregate threshold amount of $3,700 for therapy services, including OPD therapy services, for a year. There are two separate $3,700 aggregate annual thresholds: (1) physical therapy and speech-language pathology services, and (2) occupational therapy services.
Section 1104 - Extension of Ambulance Add-On Payments - Section 1104 extends the following two Job Creation Act ambulance payment provisions: (1) the 3 percent increase in the ambulance fee schedule amounts for covered ground ambulance transports that originate in rural areas and the 2 percent increase for covered ground ambulance transports that originate in urban areas is extended through March 31, 2014; and (2) the provision relating to payment for ground ambulance services that increases the base rate for transports originating in an area that is within the lowest 25th percentile of all rural areas arrayed by population density (known as the “super rural” bonus) is extended through March 31, 2014. The provision relating to air ambulance services that continued to treat as rural any area that was designated as rural on December 31, 2006, for purposes of payment under the ambulance fee schedule, expired on June 30, 2013.
Section 1105 - Extension of Medicare Inpatient Hospital Payment Adjustment for Low-Volume Hospitals - The Affordable Care Act allowed qualifying low-volume hospitals to receive add-on payments based on the number of Medicare discharges from the hospital. To qualify, the hospital must have less than 1,600 Medicare discharges and be 15 miles or greater from the nearest like hospital. This provision extends the payment adjustment through March 31, 2014, retroactive to October 1, 2013. Be on the alert for further information about implementation of this provision.
Section 1106 - Extension of the Medicare-Dependent Hospital (MDH) Program - The MDH program provides enhanced payment to support small rural hospitals for which Medicare patients make up a significant percentage of inpatient days or discharges. This provision extends the MDH program until March 31, 2014, and is retroactive to October 1, 2013. Be on the alert for further information about implementation of this provision.
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Saturday, December 28, 2013
President Obama Signs the Pathway for SGR Reform Act of 2013
Monday, December 23, 2013
Administrative Simplification News: CAQH CORE Training on Market Based Review TODAY
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| Centers for Medicare & Medicaid Services (CMS) has sent this update. To contact Centers for Medicare & Medicaid Services (CMS) go to our contact us page. |
Friday, December 20, 2013
MLN Connects Provider eNews for Thursday December 19, 2013
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Thursday December 19, 2013
Two important notes for you this week:
Due to the holidays, the next regular edition of the eNews will be released Thursday, January 9.
Happy Holidays and Happy New Year!
MLN Connects™ National Provider Calls
Announcements
Claims, Pricers, and Codes
MLN Educational Products
MLN Connects™ National Provider Calls2-Midnight Benchmark for Inpatient Hospital Admissions — Registration Now Open
Tuesday, January 14; 1:30-3pm ET
This MLN Connects Call provides an overview of the inpatient hospital admission and medical review criteria (also known as the 2-Midnight Rule) that was released on August 2, 2013 in the FY 2014 Inpatient Prospective Payment System/Long-Term Care Hospital final rule (CMS-1599-F). CMS will present case scenarios on the application of the rule to sample medical records. Following the presentation, CMS will address frequently asked questions received from providers.
Agenda:
Target Audience: Hospitals, physicians and non-physician practitioners, case managers, medical and specialty societies, and other healthcare professionals.
Continuing education credit may be awarded for participation in certain MLN Connects Calls. Visit the Continuing Education Credit Information web page to learn more.
End-Stage Renal Disease Quality Incentive Program Payment Year 2016 Final Rule — Register Now
Wednesday, January 15; 2-3:30pm ET
On January 15, CMS, Center for Clinical Standards and Quality (CCSQ) will host an MLN Connects™ Call on the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP). The ESRD QIP is a pay-for-performance quality program that ties a facility's performance to a payment reduction over the course of a payment year (PY). This MLN Connects Call will focus on the final rule for operationalizing the ESRD QIP in PY 2016, which was put on display on November 22, 2013.
The performance period for PY 2016 will begin on January 1, 2014. Facilities and other stakeholders should take steps to understand the contours of the program. After the presentation, participants will have an opportunity to ask questions.
Agenda:
Target Audience: Dialysis clinics and organizations, nephrologists, hospitals with dialysis units, billers/coders and quality improvement experts, and other interested stakeholders.
Continuing education credit may be awarded for participation in certain MLN Connects Calls. Visit the Continuing Education Credit Information web page to learn more.
2012 Quality and Resource Use Reports Overview and December Addendum — Registration Now Open
Thursday, January 16; 2:30-4pm ET
This MLN Connects Call will provide an overview of the 2012 Quality and Resource Use Reports (QRURs), including a review of the December addendum and how to interpret and use the data in the report.
On September 16, CMS released the 2012 QRURs to group practices with 25 or more eligible professionals (EPs). The QRUR previews each group’s performance on quality and cost measures that could be used to calculate the group’s Value-Based Payment Modifier in 2015. On December 23, CMS released an addendum to the 2012 QRURs to include individual eligible professional (EP) PQRS performance data. The addendum will be available for all group practices with 25 or more EPs for which at least one EP reported PQRS measures as an individual in 2012 and was found to be incentive eligible.
Agenda:
Target Audience: Groups with 25 or more eligible professionals.
Continuing education credit may be awarded for participation in certain MLN Connects Calls. Visit the Continuing Education Credit Information web page to learn more.
National Partnership to Improve Dementia Care in Nursing Homes — Registration Now Open
Wednesday, February 26; 2-3:30pm ET
The CMS National Partnership to Improve Dementia Care in Nursing homes was developed to improve dementia care through the use of individualized, comprehensive care approaches. The partnership promotes a systematic process to evaluate each person and identify approaches that are most likely to benefit that individual. The goal of the partnership is to continue to reduce the use of unnecessary antipsychotic medications, as well as other potentially harmful medications in nursing homes and eventually other care settings as well.
During this MLN Connects Call, a CMS subject matter expert will discuss the critical role of both state and federal surveyors in the implementation of the partnership. Additional speakers will be presenting on the importance of leadership, as well as the strong correlation that exists between proper pain assessment and antipsychotic medication use. A question and answer session will follow the presentation.
Agenda:
Target Audience: Consumer and advocacy groups, nursing home providers, surveyor community, prescribers, professional associations, and other interested stakeholders.
Continuing education credit may be awarded for participation in certain MLN Connects Calls. Visit the Continuing Education Credit Information web page to learn more.
Did You Miss This MLN Connects Call?
Call materials for MLN Connects™ Calls are located on the Calls and Events web page. New materials are now available for the following call:
AnnouncementsRemember To Ask, Have You Gotten Your Flu Shot?
Increases in influenza activity across the U.S. are expected in the coming weeks. The Centers for Disease Control and Prevention (CDC) recommends a yearly flu vaccination as the first and most important step in protecting against flu and its potentially serious complications. The CDC recommends that you assess vaccination status with each patient visit, encourage seasonal influenza vaccination, and vaccinate or refer to a vaccine provider when appropriate. Health care providers should also get vaccinated and continue offering and encouraging flu vaccination among staff, colleagues, and patients.
Generally, Medicare Part B covers one influenza vaccination and its administration per influenza season for Medicare beneficiaries without co-pay or deductible. Note: The influenza vaccine is not a Part D-covered drug.
For more information on coverage and billing of the influenza vaccine and its administration, please visit:
DMEPOS Competitive Bidding Program: January 1, 2014 Round 1 Recompete Implementation — Resources
Educational Resources Reminder
CMS is required by law to recompete contracts under the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program at least once every three years. The Round 1 Rebid contracts will expire on December 31, 2013, and the Round 1 Recompete contracts and prices are scheduled to go into effect on January 1, 2014.
When a round of the Program becomes effective in a competitive bidding area (CBA), beneficiaries with Original Medicare who obtain competitively bid items in that CBA must obtain these items from a contract supplier for that round in order for Medicare to pay, unless an exception applies. Educational resources are available on the CMS website. Materials to assist you with beneficiary inquiries about the program are also available.
CBIC Liaison Reminder
Competitive Bidding Implementation Contractor (CBIC) liaisons are available to assist suppliers, referral agents, and other key stakeholders with questions and concerns about the Medicare DMEPOS Competitive Bidding Program. The liaisons can provide assistance with issues such as:
Step-by-Step Instructions for Using the I&A System to Access PECOS, EHR, and NPPES
Changes have been made to simplify the way providers and suppliers access the Provider Enrollment Chain and Ownership System (PECOS), the Electronic Health Records (EHR) Registration and Attestation System, and the National Plan and Provider Enumeration System (NPPES).CMS has developed the following tools to make it easy for you to use the Identity and Access management (I&A) System used to access PECOS, EHR and NPPES.
Questions?
Frequently Asked Questions: Answers to common questions about registration, who should register, and how to manage your account.
HHS Announces Affordable Care Act Mental Health Services Funding
On December 10, HHS announced that it plans to issue a $50 million funding opportunity announcement to help Community Health Centers establish or expand behavioral health services for people living with mental illness, and drug and alcohol problems. Community Health Centers will be able to use these new funds, made available through the Affordable Care Act, for efforts such as hiring new mental health and substance use disorder professionals, adding mental health and substance use disorder services, and employing team-based models of care. It is estimated these awards will support behavioral health expansion in approximately 200 existing health centers nationwide.
More Than 25 Million Original Medicare Beneficiaries Received Free Preventive Services through November 2013
According to new data released by CMS on December 17, more than 25.4 million people covered by Original Medicare received at least one preventive service at no cost to them during the first eleven months of 2013 because of the Affordable Care Act. This announcement exceeds the comparable figure from last November, when an estimated 24.7 million people with Original Medicare received one or more preventive benefits at no out of pocket costs by this point in time during 2012. When factoring in Medicare Advantage utilization rates and a full year of experience, an estimated 34.1 million people with Medicare took advantage of at least one preventive service in 2012. Moreover, in the first eleven months of 2013, more than 3.5 million beneficiaries with Original Medicare took advantage of the Annual Wellness Visit established by the health care law – a significant increase from the 2.8 million who used this service by this point in the year in 2012.
LTCH FY 2015 Payment Update Determination: Data Submission Deadlines
Long-Term Care Hospitals (LTCH) should be collecting and submitting data for the FY 2015 payment update determination required by the LTCH Quality Reporting (LTCHQR) Program. Per the FY 2013 IPPS/LTCH PPS Final Rule (77 FR 53614 through 53637, and 53667 through 53672), data on three measures will be collected from January 1 through December 31, 2013 for FY 2015 Payment Update Determination:
The deadlines for final data submission for FY 2015 Payment Update Determination are:
Reminder: The submission deadlines — August 15, 2013 for January through March 2013 data and November 15, 2013 for April through June 2013 data — that will affect the FY 2015 Payment Update Determination have passed.
Upcoming Deadline for EPs in EHR Incentive Programs; Prepare for Attestation
December 31, 2013, is an important deadline for eligible professionals (EPs) participating in the EHR Incentive Programs. It marks the end of the calendar year and the last day of the 2013 meaningful use program year.
Attestation DeadlineIf you are an EP participating in the Medicare EHR Incentive Program, you have until February 28, 2014, to attest to demonstrating meaningful use of the data collected during the reporting period for the 2013 calendar year. You must attest by 11:59pm ET on February 28 to demonstrate meaningful use. If you are participating in the Medicaid EHR Incentive Program, please refer to your state’s deadlines for attestation information. You must attest to demonstrating meaningful use every year to receive an incentive and avoid a payment adjustment.
Payment AdjustmentsPayment adjustments will be applied beginning January 1, 2015, if you have not successfully demonstrated meaningful use. The adjustment is determined by the reporting period in a prior year. For more information, visit the payment adjustment tipsheet If you are eligible to participate in both the Medicare and Medicaid EHR Incentive Programs, you must demonstrate meaningful use to avoid the payment adjustments. You may demonstrate meaningful use under either Medicare or Medicaid. If you are only eligible to participate in the Medicaid EHR Incentive Program, you are not subject to these payment adjustments.
EPs in 2014January 1, 2014 marks many important milestones for EPs participating in the EHR Incentive Programs, including:
Resources
Plan AheadReview all of the important dates for the EHR Incentive Programs on the Health Information Technology Timeline
Request an Informal Review of 2014 eRx Payment Adjustment
Eligible professionals and group practices (who self-nominated for the 2012 and/or 2013 Electronic Prescribing (eRx) group practice reporting option) who were not successful electronic prescribers under the 2012 or 2013 eRx Incentive Program will be subject to a payment adjustment in 2014. CMS will notify those eligible professionals and group practices who will be subject to the 2014 eRx payment adjustment. The 2014 eRx payment adjustment will result in an eligible professional or group practice receiving 98.0% of his or her Medicare Part B physician fee schedule (PFS) allowed charges amount that would otherwise apply to such services for all charges with dates of service from January 1 through December 31, 2014.
Request an Informal Review
CMS has implemented an informal review process for the 2014 eRx payment adjustment. An informal review may be requested if the eligible professional or group practice receives notification from CMS confirming they will be subject to the 2014 eRx payment adjustment or they did not meet the requirements to avoid the 2014 eRx payment adjustment. Informal review requests will be accepted through February 28, 2014. Eligible professionals and group practices should submit their eRx informal review request via email to the informal review mailbox at eRxInformalReview@cms.hhs.gov. Complete instructions on how to request an informal review are available in the 2014 eRx Payment Adjustment Informal Review Made Simple educational document.
QuestionsFor all other questions related to the eRx Incentive Program, please contact the QualityNet Help Desk at 866-288-8912 (TTY 1-877-715-6222) or viaqnetsupport@sdps.org. They are available Monday through Friday from 7am-7pm CT.
CMS Furnishes Final List of Off-The-Shelf Orthotic HCPCS Codes
On August 12, 2013, CMS issued guidance identifying specific Healthcare Common Procedure Coding System (HCPCS) codes that are considered Off-The-Shelf (OTS) orthotics. This posting on the OTS Orthotics web page provides the final OTS HCPCS codes approved by the HCPCS Alpha Numeric Workgroup effective January 1, 2014.
Section 1847(a)(2) of the Social Security Act (the Act) defines OTS orthotics as those orthotics described in section 1861(s)(9) of the Act for which payment would otherwise be made under section 1834(h) of the Act, which require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit to the individual. Orthotics that are currently paid under section 1834(h) of the Act and are described in section 1861(s)(9) of the Act are leg, arm, back and neck braces. The Medicare Benefit Policy Manual (Publication 100-02), Chapter 15, Section 130 provides the longstanding Medicare definition of “braces.” Braces are defined in this section as “rigid or semi-rigid devices which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.”
Suppliers of any orthotic other than an OTS orthotic must be in compliance with Appendix C of the DMEPOS quality standards, which specifies that suppliers must possess specialized education, training, and experience in fitting and certification and/or licensing.
Please note that in some cases there are two codes in the HCPCS that may both describe a particular prefabricated orthotic product, one code for when the device is furnished OTS, and a second code for when the device is furnished with custom fitting. In these cases, and in the case of any code for a prefabricated orthotic that requires more than minimal self-adjustment and requires expertise in fitting or customizing, the code that describes a custom fitted orthotic cannot be used unless the custom fitting services have been performed and the supplier is in compliance with Appendix C of the DMEPOS quality standards.
CMS regulations at 42 CFR 414.402 also define the term “minimal self-adjustment” to mean an adjustment that the beneficiary, caretaker for the beneficiary, or supplier of the device can perform and that does not require the services of a certified orthotist (that is, an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification) or an individual who has specialized training.
To view the final list of 2014 OTS orthotic HCPCS codes, please visit the CMS DMEPOS Fee Schedule website and click on “OTS Orthotics.”
MLN Educational Products“Mental Health Services” Booklet — Revised
The “Mental Health Services” Booklet (ICN 903195) was revised and is now available in downloadable format. This booklet is designed to provide education on mental health services. It includes the following information: covered and non-covered mental health services, eligible professionals, outpatient and inpatient psychiatric hospital services, same day billing guidelines, and National Correct Coding Initiative.
“Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Information for Pharmacies” Fact Sheet — Reminder
The “Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Information for Pharmacies” Fact Sheet (ICN 905711) is available in a downloadable format. This fact sheet is designed to provide education for pharmacies on DMEPOS. It includes information on accreditation by CMS-approved independent national Accreditation Organization (AO) as well as information if a pharmacy wants to be considered for an exemption from the accreditation requirements.
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