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Tag Archives: Announcement

[Announcement] Private Payor Prices Will Be Used By Medicare to Set Payment Rates for Clinical Diagnostic Laboratory Tests Beginning in 2018

Clinical Lab Tests

On June 17, CMS released a final rule implementing Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA), requiring laboratories performing clinical diagnostic laboratory tests to report the amounts paid by private insurers for laboratory tests. Medicare will use these private insurer rates to calculate Medicare payment rates for laboratory tests paid under the Clinical Laboratory Fee Schedule (CLFS) beginning January 1, 2018.

The final rule includes provisions to ease administrative burdens for physician office laboratories and smaller independent laboratories. The final rule will generally require reporting entities to report private payor rates and test volumes for laboratory tests if an applicable laboratory receives at least $ 12,500 in Medicare revenues from laboratory services paid under the CLFS and more than 50 percent of its Medicare revenues from laboratory and/or physician services.

For the system’s first year, laboratories will collect private payor data from January 1, 2016, through June 30, 2016, and report it to CMS between January 1, 2017, and March 31, 2017. CMS will calculate and post the new Medicare rates by early November 2017. These rates will take effect on January 1, 2018.

For More Information:

 

See the full text of this excerpted CMS press release (issued June 17).

The Medical Management Institute – MMI – Medical Coding News & MMI Updates

[Announcement] Helping Small Practices Prepare for the Quality Payment Program

The Quality Payment Program is proposed to implement the new, bipartisan law changing how Medicare pays clinicians, known as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). On June 20, HHS announced $ 20 million to fund on-the-ground training and education for Medicare clinicians in individual or small group practices of 15 clinicians or fewer. These funds will help provide hands-on training tailored to small practices, especially those that practice in historically under-resourced areas including rural areas, health professional shortage areas, and medically underserved areas.

As required by MACRA, HHS will continue to award $ 20 million each year over the next five years, providing $ 100 million in total to help small practices successfully participate in the Quality Payment Program. In order to receive funding, organizations must demonstrate their ability to strategically provide customized training to clinicians. And, most importantly, these organizations will provide education and consultation about the Quality Payment Program at no cost to the clinician or their practice. Awardees will be announced by November 2016.

For More Information:

 

See the full text of this excerpted HHS press release (issued June 20).

The Medical Management Institute – MMI – Medical Coding News & MMI Updates

[Announcement] Effective July 1st, 77295 and 77300 Can Be Reported Together

In March 2016, CMS and the NCCI announced that they would remove the current edit prohibiting the reporting of CPT codes 77295 and 77300. The change will take effect today, July 1, 2016 (retroactive to January 1, 2016) and will be finalized in the July version of the NCCI Manual. Reporting requirements may vary by payer.

Providers (hospitals, physicians and freestanding cancer centers) should continue to track and capture the supported work of code 77300 during the 3D planning process. When the transmittal is released, providers will be able to submit those charges, along with the retroactive charges, for payment and in accordance with documentation guidelines and published Medically Unlikely Edits (MUEs).

Background: CMS originally implemented the prohibition of reporting these codes together (implemented January 1, 2016) because they believed the work of 77300 was integral to the work of 77295. Therefore, it should not be considered a separately reportable procedure. Opponents believed that this NCCI edit misinterpreted the work performed under these codes, resulting in unfair and significant payment cuts for radiation oncologists and facilities who were performing these critical procedures. This edit has since been removed (announced March 2016, effective July 1, 2016).

The Codes in Question:

77300: Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician.

77295: 3-dimensional radiotherapy plans, including dose-volume histograms.

 

The Medical Management Institute – MMI – Medical Coding News & MMI Updates

[Announcement] NCCI Will No Longer Allow 77300 and 77295 to be Reported Together

The 2016 National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services was released for services effective January 1, 2016. NCCI is a contractor for the Centers for Medicare and Medicaid Services (CMS) that aims to prevent improper payment when incorrect code combinations are reported.

Beginning January 1, 2016, NCCI will no longer allow the following CPT codes to be reported together:

77300: Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician.
77295: 3-dimensional radiotherapy plans, including dose-volume histograms.

 

CMS has implemented an edit on these codes because the agency believes the work of 77300 is integral to the work of 77295, and therefore is not considered a separately reportable procedure. 

The Medical Management Institute – MMI – Medical Coding News & MMI Updates

[Announcement] NCCI Has Removed the Current Edit Prohibiting 77295 and 77300 from Being Reported Together

CMS and the NCCI has removed the current edit prohibiting the reporting of CPT codes 77295 and 77300 together, effective July 1, 2016. The change will be finalized in the July version of the NCCI Manual and will be retroactive to January 1, 2016. Reporting requirements may vary by payer:

Claims reported to Medicare contractors: 

Claims for CPT codes 77295 and 77300 should not be reported together until the edit is removed on July 1, 2016. Practice billing systems can begin capturing charges for 77300; however, the charges should not be released to Medicare until July 1, 2016. All prospective and retrospective pending charges for 77300 may be released on or after July 1, 2016.

    Claims reported to private payers:

    Depending on state guidelines and individual payer policies, some private payers may not permit claims to be submitted after a certain period of time has passed. Therefore, practices could consider submitting charges for 77300 to commercial payers prior to July 1, 2016. Refer to your payer’s individual reporting policies for guidance on when to submit claims for 77295 and 77300. 

       

      Click here to read the original article on the prohibition of reporting 77295 and 77300 together. 

      The Medical Management Institute – MMI – Medical Coding News & MMI Updates

      [Announcement] Change for the use of JW Modifier

      [UPDATE 6/1/2016: CMS announced a delay in implementing Change Request 9603 to January 1, 2017]

      Effective January 1, 2017, when processing claims for drugs and biologicals (except those provided under the Competitive Acquisition Program for Part B drugs and biologicals (CAP), local contractors shall require the use of the modifier JW to identify unused drugs or biologicals from single use vials or single use packages that are appropriately discarded. This modifier, billed on a separate line, will provide payment for the amount of discarded drug or biological.

      What is the Current Policy?

      The current policy allows contractors the discretion to determine whether to require the JW modifier for any claims with discarded drugs or biologicals, and the specific details regarding how the discarded drug or biological information should be documented. In order to more effectively identify and monitor billing and payment for discarded drugs and biologicals, CMS is revising this policy to require the uniform use of the JW modifier for all claims with discarded Part B drugs and biologicals.

      For Example

      A single use vial that is labeled to contain 100 units of a drug has 95 units administered to the patient and 5 units discarded. The 95 unit dose is billed on one line, while the discarded 5 units shall be billed on another line by using the JW modifier. Both line items would be processed for payment. Providers must record the discarded amounts of drugs and biologicals in the patient’s medical record.

      The JW modifier is only applied to the amount of drug or biological that is discarded. A situation in which the JW modifier is not permitted is when the actual dose of the drug or biological administered is less than the billing unit. For example, one billing unit for a drug is equal to 10mg of the drug in a single use vial. A 7mg dose is administered to a patient while 3mg of the remaining drug is discarded. The 7mg dose is billed using one billing unit that represents 10mg on a single line item. The single line item of 1 unit would be processed for payment of the total 10mg of drug administered and discarded. Billing another unit on a separate line item with the JW modifier for the discarded 3mg of drug is not permitted because it would result in overpayment. Therefore, when the billing unit is equal to or greater than the total actual dose and the amount discarded, the use of the JW modifier is not permitted.

      CAP Drugs

      The JW modifier is not used on claims for CAP drugs. For CAP drugs, see subsection 100.2.9 – Submission of Claims With the Modifier JW, “Drug or Biological Amount Discarded/Not Administered to Any Patient”, for additional discussion of the discarded remainder of a vial or other packaged drug or biological in the CAP.

      NOTE:

      Multi-use vials are not subject to payment for discarded amounts of drug or biological.

       

      [PDF] CMS transmittal 3530, Change Request 9603: Click Here

      The Medical Management Institute – MMI – Medical Coding News & MMI Updates

      [Announcement] 2016 Annual Update of HCPCS Codes Use for SNF

      October Quarterly Update to 2016 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement

      › Effective Date: October 1, 2016
      › Implementation Date: October 3, 2016

        Provider Types Affected: This information is intended for physicians, providers, and suppliers submitting claims to all Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries who are in a Part A Skilled Nursing Facility (SNF) stay.

        Provider Action Needed: This information is based on Change Request (CR) 9688 updates to the lists of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the consolidated billing provision of the SNF Prospective Payment System (PPS). Changes to Current Procedure Terminology (CPT)/HCPCS codes and Medicare Physician Fee Schedule designations will be used to revise CWF edits to allow MACs to make appropriate payments in accordance with policy for SNF consolidated billing in the “Medicare Claims Processing Manual,” Chapter 6, Section 20.6. Make sure your staffs are aware of these updates.

        Background: The Centers for Medicare & Medicaid Services (CMS) periodically updates the lists of HCPCS codes that are excluded from the Consolidated Billing (CB) provision of the SNF PPS. Services excluded from SNF PPS and CB may be paid to providers, other than SNFs, for beneficiaries, even when in a SNF stay. Services not appearing on the exclusion lists submitted on claims to MACs, including Durable Medical Equipment MACs (DME).

         

        Please note: “Shall” denotes a mandatory requirement, and “should” denotes an optional requirement.

         

        II. Business Requirement Table

        II. Business Requirements Table Continued

        III. Provider Education Table

         

        Helpful Links

        [PDF] Recurring Update Notification from CMS [Pub 100-04 Medicare Claims Processing)

        [PDF] MLN Matters® Article [MM9688, CR 9688]

        The Medical Management Institute – MMI – Medical Coding News & MMI Updates

        [Announcement] Hospice Benefit: Final FY 2017 Payment and Policy Change

        Hospice

        Originally Published in MLN Connects

        On July 29, CMS issued a final rule (CMS-1652-F) outlining FY 2017 Medicare payment rates and wage index and the Hospice Quality Reporting Program (QRP) for hospices serving Medicare beneficiaries. As finalized, hospices would see a 2.1 percent ($ 350 million) increase in their payments for FY 2017 (reflecting an estimated 2.7 percent inpatient hospital market basket update, reduced by a 0.3 percentage point productivity adjustment and a 0.3 percentage point adjustment required by law).

        Changes to the Hospice QRP:

        • Provides a description of the Hospice CAHPS® Survey and outlines participation requirements for the FY 2019 and FY 2020 annual payment updates
        • Finalizes two new quality measures for FY 2017
        • CMS expects to begin public reporting hospice quality measures via a Compare site in CY 2017

        Enhanced Data Collection:

        • CMS is considering enhancing the current Hospice Item Set (HIS) data collection instrument to be more in line with other post-acute care settings
        • This revised data collection instrument would be a comprehensive patient assessment instrument, rather than the current chart abstraction tool

        For More Information:

        • Final Rule will become effective on October 1, 2016
        • Hospice Center website

         

        See the full text of this excerpted CMS fact sheet (issued July 29).

        The Medical Management Institute – MMI – Medical Coding News & MMI Updates

        [Announcement] SNFs: Final FY 2017 Payment and Policy Changes

        On July 29, CMS issued a final rule (CMS-1645-F) outlining FY 2017 Medicare payment policies and rates for the Skilled Nursing Facility (SNF) Prospective Payment System (PPS), the SNF Quality Reporting Program (QRP), and the SNF Value-Based Purchasing (VBP) Program. CMS projects that aggregate payments to SNFs will increase in FY 2017 by $ 920 million, or 2.4 percent, from payments in FY 2016. This estimated increase is attributable to a 2.7 percent market basket increase reduced by 0.3 percentage points, in accordance with the multifactor productivity adjustment required by law.

        Changes to the SNF QRP:

        • Adopts three measures to meet the resource use and other measure domains and one measure to satisfy the domain of medication reconciliation
        • SNFs that fail to submit the required quality data to CMS will be subject to a 2 percentage point reduction to the annual market basket percentage update factor for fiscal years beginning with FY 2018
        • Policies and procedures associated with public reporting are being finalized, including the reporting timelines, preview period, review and correction of assessment-based and claims-based quality measure data, and the provision of confidential feedback reports to SNFs

        SNF VBP Program:

        • Specifies the SNF 30-Day Potentially Preventable Readmission Measure, (SNFPPR), as the all-cause, all-condition risk-adjusted potentially preventable hospital readmission measure as required by law

        • Finalized additional policies, including establishing performance standards, establishing baseline and performance periods, adopting a performance scoring methodology, and providing confidential feedback reports to SNFs

        For More Information:

        • Final Rule will become effective on October 1, 2016
        • SNF PPS website
        • SNF QRP webpage
        • SNF VBP webpage

         

        See the full text of this excerpted CMS fact sheet (issued July 29).

        The Medical Management Institute – MMI – Medical Coding News & MMI Updates

        [Announcement] IRFs: Final FY 2017 Payment and Policy Change

        On July 29, CMS issued a final rule (CMS-1647-F) outlining FY 2017 Medicare payment policies and rates for the Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) and the IRF Quality Reporting Program (QRP). CMS is updating the IRF PPS payments for FY 2017 to reflect an estimated 1.65 percent increase factor (reflecting an IRF-specific market basket estimate of 2.7 percent, reduced by a 0.3 percentage point multi-factor productivity adjustment and a 0.75 percentage point reduction required by law). An additional approximate 0.3 percent increase to aggregate payments due to updating the outlier threshold results in an overall estimated update of approximately 1.9 percent (or $ 145 million), relative to payments in FY 2016.

        • No changes to the facility-level adjustment
        • Rural adjustment transition: Continue year two of the phase-out of the 14.9 percent rural adjustment for IRF providers in areas that were designated as rural and changed to urban under the new Office of Management and Budget delineations

          Changes to the IRF QRP:

          • Adopts three measures to meet the resource use and other measure domains and one measure to satisfy the domain of medication reconciliation
          • IRFs that fail to submit the required quality data to CMS will be subject to a 2 percentage point reduction to their applicable FY annual increase factor
          • Begin publically reporting IRF quality data in fall 2016
          • Adopted an extension of the time frame for submission of exception and extension requests for extraordinary circumstances from 30 days to 90 days from the date of the qualifying event

            For More Information:

            • Final Rule will become effective on October 1, 2016
            • IRF PPS website
            • IRF QRP website

              See the full text of this excerpted CMS fact sheet (issued July 29).

              The Medical Management Institute – MMI – Medical Coding News & MMI Updates