This week's Medicare updates include billing and coding updates for COVID-19 booster shots, new items on the OIG Work Plan, a proposed decision memo on an NCD for Transvenous (Catheter) Pulmonary Embolectomy, and more! 

A version of this article was first published August 25, 2021, by HCPro's Revenue Cycle Advisor, a sibling publication to HealthLeaders.

Proposed Decision Memo: Transvenous (Catheter) Pulmonary Embolectomy

On August 11, CMS published a Proposed Decision Memo regarding the removal of the NCD for Transvenous (Catheter) Pulmonary Embolectomy (NCD 240.6). CMS would instead allow MACs to make coverage determinations for this procedure. 

There is a 30-day comment period on this decision which closes on September 10.

Medicare Updates Coding for COVID-19 Booster Shots

On August 16, CMS published a Special Edition MLN Connects regarding additional doses of COVID-19 vaccines. It included links to the revised EUAs for the Pfizer and Moderna COVID-19 vaccines which now allow for a third dose.

On August 19, CMS updated its COVID-19 Vaccines and Monoclonal Antibodies webpage with new codes for third doses of the Pfizer (0003A) and Moderna (0013A) COVID-19 vaccines. Payment for the third doses of these vaccines will remain at $40. 

Updated OIG Work Plan

On August 16, the OIG updated its Work Plan with the following new item:

• Audit of Medicare Part B Opioid-Use-Disorder Treatment Services Provided by Opioid Treatment Programs
• Audit of Medicare Emergency Department Evaluation and Management Services
• Data Snapshot: Review of Beneficiaries Relationships With Providers for Telehealth Services

Medicare Paid New Hospitals Three Times More for Capital Costs Than They Would Have Been Paid Under the IPPS

On August 16, CMS published a Report regarding the potential cost savings to Medicare if the exemption for new hospitals from payment for capital costs under the IPPS were removed and capital payments to new hospitals were made under the IPPS instead of through cost reimbursement. The OIG identified significant potential savings, as it found that new hospitals were paid three times more under this exception than they would be if they had been paid for capital costs under the IPPS. 

The exemption exists because CMS said hospitals may not have adequate Medicare utilization in the first two years and may have incurred significant start-up costs. However, the OIG said it found that average Medicare-related capital costs were only 3% higher and average Medicare utilization was only 15% lower for new hospitals in their first two years than in the subsequent two years of operation. The OIG also said most of the new hospitals in its review were also part of chain organizations that might have been able to provide reserve capital to the new hospitals if necessary.

The OIG recommends CMS review the findings in the report and possibly change its regulations to require new hospitals to have Medicare capital costs paid through the IPPS with an option for payment adjustments or supplemental payment if necessary. CMS concurred with the recommendation to review the findings and said it will determine whether any modifications to this policy should be proposed in future rule-making. 

Comparison of Average Sales Prices (ASP) and Average Manufacturer Prices (AMP): Results for the First Quarter of 2021

On August 17, the OIG published a Report regarding drugs for which the ASP exceeds the AMP by 5% or more for two consecutive quarters or three of the previous four quarters. When this happens, CMS substitutes 103% of the AMP for the ASP-based reimbursement. In the first quarter of 2021, six drug codes met this price substitution criteria. Six additional codes exceeded the 5% threshold but were identified as being in short supply. Another five codes had ASPs exceeding the AMPs by at least 5% in the first quarter of 2021 but didn't meet other price substitution criteria. The OIG will provide these results to CMS for review.

Updated Corporate Integrity Agreement Documents

On August 17, the OIG published information on new Corporate Integrity Agreements with the following entity:

• Azinheira, Lisa and L.A. Vision, LLC, of Hartford, CT

Biden-Harris Administration Requires COVID-19 Vaccines for All Nursing Home Staff 

On August 18, CMS published a Press Release to announce that it will require all staff at Medicare and Medicaid-participating nursing homes nationwide to be vaccinated against COVID-19. CMS said it will undergo the necessary steps in the rule-making process over the next few weeks to finalize this policy, and it strongly encourages nursing home residents and staff members to get vaccinated in the interim. 

Update to Nursing and Allied Health Education Medicare Advantage Payment Rates - CY 2019

On August 19, CMS published One-Time Notification Transmittal 10953 regarding information for the MACs on payment rates to use when computing the CY 2019 nursing and allied health Medicare Advantage add-on payments. 

Effective date: November 19, 2021

Implementation date: November 19, 2021

Update to the Internet Only Manual Medicare Claims Processing Manual, Chapter 3, Section 40.2.4 IPPS Transfers Between Hospitals 

On August 19,  CMS published Medicare Claims Processing Transmittal 10952 regarding updates to the manual to change the language for acute care and post-acute care transfers and discharge patient status codes so the language in the manual is consistent with the definitions of discharges and transfers as defined in 42 CFR 412.4(a) and (b). 

Effective date: September 20, 2021

Implementation date: September 20, 2021

Kidney Care Choices (KCC) Comprehensive Kidney Care Contracting (CKCC) - Payment and Benefit Enhancements - Implementation

On August 19, CMS published Demonstrations Transmittal 10715, which rescinds and replaces Transmittal 10662, dated March 10, 2021, to revise the background section and to revise business requirements 11915.8, 11915.13.3, 11915.13.4, 11915.13.6, 11915.14.1, 11915.14.2, 11915.15.1, 11915.27.1, 11915.37, and 11915.38.1. The correction also updates the Interface Control Document and adds business requirements 11915.27.1.1 and 11915.37.1. The transmittal is no longer sensitive and may now be posted to the internet. The original transmittal was published regarding implementation of the Chronic Kidney Disease Quarterly Capitation Payment mechanism and to implement various benefit enhancements, including telehealth, post-discharge home visit, 3-day SNF rule waiver benefit enhancements, and more. 

Effective date: April 1, 2021; July 1, 2021 - BRs 11915.36 through 11915.71

Implementation date: April 5, 2021; July 6, 2021 - BRs 11915.36 through 11915.71

Kidney Care Choices (KCC) Comprehensive Kidney Care Contracting (CKCC) - Payment Mechanism and Benefit Enhancements - Implementation

On August 19, CMS published Demonstrations Transmittal 10714, which rescinds and replaces Transmittal 10661, dated March 9, 2021, to revise the background section and to revise business requirements 11914.4, 11914.8, 11914.9, 11914.10, 11914.11, 11914.12, 11914.22, 11914.27.1, and 11914.45. The correction also updates the Interface Control Document and adds business requirements 11914.27.1.1 and 11914.45.1. The transmittal is no longer sensitive and may now be posted to the internet. The original transmittal was published regarding implementation of the Chronic Kidney Disease Quarterly Capitation Payment mechanism and to implement various benefit enhancements, including telehealth, post-discharge home visit, kidney disease education benefit enhancements, and more. 

Effective date: April 1, 2021; July 1, 2021 - BRs 11914.45 through 11914.64

Implementation date: April 5, 2021; July 6, 2021 - BRs 11914.45 through 11914.64

Hospital Provider Compliance Audit: Jewish Hospital

On August 19, the OIG published a Review of whether Jewish Hospital complied with Medicare requirements for billing inpatient and outpatient services for certain claims that were potentially at risk for billing errors. The OIG determined that Jewish Hospital did not comply with requirements on 38 of the 100 claims reviewed, with 34 errors pertaining to inpatient claims and four errors involving outpatient claims. The inpatient claim errors involved a mix of incorrectly billed inpatient rehabilitation facility (IRF) claims (31), and incorrectly billed DRG codes (three). The outpatient claim errors involved incorrect use of the 59 or XU modifier. These errors resulted in an estimated $13.5 million in overpayments for the audit period.     

The OIG recommends Jewish Hospital refund the $13.5 million in estimated overpayments; exercise reasonable diligence to identify, report, and return overpayments in accordance with the 60-day rule; and strengthen controls to ensure compliance with Medicare requirements. The hospital disagreed with the majority of the OIG's findings--including all IRF findings--and claimed the OIG’s medical review contractor had a highly selective reading of medical records and never met with Jewish Hospital's independent medical review contractor to discuss the claims as Jewish Hospital had expected. The OIG maintained its original findings and recommendations and said its contract with the independent medical reviewer does not allow for direct interaction between it and the hospital. However, the OIG said that because the hospital never provided additional documentation on the claims in contention, the original determinations stand.

Advisory Opinion No. 21-11

On August 19, the OIG published an Advisory Opinion regarding whether the OIG would impose sanctions under the federal anti-kickback statute and prohibition on beneficiary inducements civil monetary penalty due to an arrangement in which a Medigap plan would contract with a preferred hospital organization (PHO) and would have network hospitals under the PHO provide discounts to the Medigap plan on policyholders' Part A inpatient deductibles. The discount would be established in advance and would be applied uniformly to all policyholders for at least one year. The Medigap plan would then offer a $100 premium credit to policyholders who select a network hospital under the PHO for a Part A covered inpatient stay. This credit would apply to the next premium payment due to the policyholder's Medigap plan after the inpatient stay. The Medigap plan would also pay the PHO a monthly, percentage-based administrative fee to compensate the PHO for establishing the hospital network and arranging for network hospitals to discount the Part A inpatient deductible. 

The OIG determined that all three streams of remuneration in this agreement would implicate the anti-kickback statute, and the premium credit from the Medigap plans to the policyholders would implicate the beneficiary inducements civil monetary penalty. However, the OIG said it would not impose sanctions in this case due to a low risk of fraud and abuse. The OIG said several elements of the arrangement factored into its decision, and it discussed these factors in depth in the Opinion.

Home Health Agency Provider Compliance Audit: Catholic Home Care

On August 20, the OIG published a Review of whether Catholic Home Care complied with Medicare requirements for billing home health services. In its original draft report, the OIG said that Catholic Home Care did not comply with requirements for 19 of the 100 home health claims reviewed. The OIG found issues pertaining to services provided to beneficiaries who did not require skilled services and dependent services not meeting coverage requirements. Catholic Home Care challenged the original findings and said the OIG's determinations did not conform with current case law, Medicare standards and guidelines, or clinical facts. Catholic Home Care also provided additional documentation for two sampled claims. After reviewing the additional documentation from Catholic Home Care, the OIG reduced the number of claims in error down to 17.

Based on overpayments for those 17 claims, the OIG estimates Catholic Home Care received $4.2 million in overpayments during the audit period. The OIG recommends Catholic Home Care identify and return any overpayments in accordance with the 60-day rule and those having been made in accordance with this recommendation as well as strengthen procedures for billing home health services.

Comment Request: Home Health Change of Care Notice; ICF/IID Survey Report Form and Supporting Regulations; more

On August 20, CMS published a Comment Request in the Federal Register regarding the following information collections:

• Home Health Change of Care Notice
• Survey Report Form for Clinical Laboratory Improvement Amendments (CLIA) and Supporting Regulations
• ICF/IID Survey Report Form and Supporting Regulations

Comments are due by October 19.

CPT® codes 63685 and 63688 are temporarily removed from the list of services that require Medicare prior authorization when performed in a hospital outpatient department.

A version of this article was first published May 19, 2021, by HCPro's Revenue Cycle Advisor, a sibling publication to HealthLeaders.

CPT® codes 63685 (insertion or replacement of spinal neurostimulator pulse generator or receiver) and 63688 (revision or removal of implanted spinal neurostimulator pulse generator or receiver) are temporarily removed from the list of services that require Medicare prior authorization when performed in a hospital outpatient department, CMS announced on May 13. For implanted spinal neurostimulators, only 63650 (implantation of spinal neurostimulator electrodes, accessed through the skin) requires prior authorization.

CMS did not comment on whether or when 63685 or 63688 may be added back to the prior authorization list. Organizations should continue to monitor CMS communications about prior authorizations.

See the full list of codes requiring prior authorization here.

The COVID-19 monoclonal antibodies are being paid under the vaccine benefit.

A version of this article was first published April 26, 2021, by HCPro's Revenue Cycle Advisor, a sibling publication to HealthLeaders.

Q: What revenue code should be attached to HCPCS codes M0239 (intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring) and M0243 (intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring)? We set it up as revenue code 260 but are getting edits to change it to 771. What are your thoughts and suggestions?

A: CMS has established the payment for these drugs under the CMS vaccine program. So, 771 is the revenue code that makes sense.

The COVID-19 monoclonal antibodies are being paid under the vaccine benefit. Please refer to this website: www.cms.gov/medicare/covid-19/monoclonal-antibody-covid-19-infusion. 

The program instruction states, “During the COVID-19 public health emergency, Medicare will cover and pay for these infusions (when furnished consistent with their respective EUAs) the same way it covers and pays for COVID-19 vaccines.”

Editor’s note: This originally appeared on NAHRI.org.

Individuals have the right to revoke their authorizations in writing at any time.

A version of this article was first published April 22, 2021, by HCPro's Revenue Cycle Advisor, a sibling publication to HealthLeaders.

Q: If an individual provides authorization for a disclosure, can the individual later revoke the authorization? Is the covered entity (CE) then required to "take back" or demand the erasure of any documentation by third parties that may have been made following the original authorization?

A: Individuals have the right to revoke their authorizations in writing at any time. However, the revocation is not effective if the CE has already released the protected health information (PHI) based on the authorization the individual signed previously. You are not required to "take back" or demand erasure of information released before the authorization was revoked.

Editor’s note: Mary Brandt, MBA, RHIA, CHE, CHPS is a healthcare consultant specializing in healthcare regulatory compliance and operations improvement. She is also an advisory board member for BOH. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions. Opinions expressed are those of the author and do not represent HCPro or ACDIS