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MLN Connects Provider eNews for December 22, 2016
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Thursday, December 22, 2016

News & Announcements

Provider Compliance

Claims, Pricers & Codes

Upcoming Events

Medicare Learning Network® Publications & Multimedia

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News & Announcements


Increased Transparency and Quality Information via New Compare Sites and Data Updates

CMS unveiled new Compare websites for both Inpatient Rehabilitation Facilities (IRFs) and Long-Term Care Hospitals (LTCHs). Under the Affordable Care Act, both IRFs and LTCHs are required to report quality data to CMS on a number of quality measures and health outcomes. These new tools take this data and put it into a format that can be used more readily by the public to get a snapshot of the quality of care each hospital provides.

National averages of the quality measure scores of Medicare-certified hospices are available on the Hospice Data Directory on as public use files. National average data will be available for two quality of care datasets – the Hospice Item Set and the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice Survey.

After releasing the Overall Hospital Quality Star Rating for the Hospital Compare website in July, we will update that overall data to reflect refreshed measure data. This update includes a refresh of the Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS) data; five new oncology care measures that were added to the Prospective Payment System-Exempt Cancer Hospital Reporting Program; and the addition of a readmission after coronary artery bypass graft surgery measure to Hospital Readmission Reduction Program.

CMS added new quality data and other information to the Physician Compare website. Additionally, CMS will release a new user-focused redesign of Physician Compare.

For More Information:

See the full text of this excerpted CMS Blog (issued December 14).


Additional Opportunities for Clinicians under the Quality Payment Program

On December 15, CMS announced more new opportunities for clinicians to join Advanced Alternative Payment Models (APMs) to improve care and earn additional incentive payments under the Quality Payment Program, which implements the Medicare Access and CHIP Reauthorization Act of 2015. Beginning in January and February 2017, CMS will open applications for new rounds of two CMS Innovation Center models for the 2018 performance year – for new practices and payers in the Comprehensive Primary Care Plus (CPC+) model and new participants in the Next Generation Accountable Care Organization (ACO) model. With these new opportunities, CMS expects that by the 2018 performance period, 25 percent of clinicians in the Quality Payment Program would be a part of these advanced models and may be eligible to earn incentive payments.

For the 2017 performance year, under the Quality Payment Program, clinicians may earn a 5 percent incentive payment through sufficient participation in the following Advanced APMs:

  • Comprehensive End-Stage Renal Disease (ESRD) Care Model (Large Dialysis Organization (LDO) arrangement)
  • Comprehensive ESRD Care Model (non-LDO two-sided risk arrangement)
  • CPC+
  • Medicare Shared Savings Program - Track 2
  • Medicare Shared Savings Program - Track 3
  • Next Generation ACO Model
  • Oncology Care Model (two-sided risk arrangement)


In 2018, we anticipate that clinicians may also earn the incentive payment through sufficient participation in the following new and existing models:

  • Medicare ACO Track 1+ Model
  • New voluntary bundled payment model
  • Comprehensive Care for Joint Replacement Payment Model (Certified Electronic Health Record Technology (CEHRT) track)
  • Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT track)

See the full text of this excerpted CMS Press Release (issued December 15).


HHS Finalizes New Medicare Alternative Payment Models

On December 20, HHS finalized new Medicare alternative payment models that continue the Administration’s progress in reforming how the health care system pays for care. This announcement finalizes new policies that:

  • Improve cardiac care: Three new payment models will support clinicians in providing care to patients who receive treatment for heart attacks, heart surgery to bypass blocked coronary arteries, or cardiac rehabilitation.
  • Further improve orthopedic care: One new payment model will support clinicians in providing care to patients who receive surgery after a hip fracture beyond hip replacement. In addition, HHS is finalizing updates to the Comprehensive Care for Joint Replacement Model, which began in April 2016.
  • Provides an Accountable Care Organization opportunity for small practices: In order to encourage more practices, especially small practices, to advance to performance-based risk, the new Medicare Accountable Care Organization (ACO) Track 1+ Model will have more limited downside risk than in Tracks 2 or 3 of the Medicare Shared Savings Program.

See the full text of this excerpted HHS Press Release (issued December 20).


CMS Releases Second Year of Home Health Utilization and Payment Data

CMS posted the second annual release of the home health agency Public Use File (PUF) on the Home Health Agencies Data webpage with data for 2014. The PUF presents summarized information on services provided to Medicare beneficiaries by home health agencies, including information on utilization, payment, submitted charges, and demographic and chronic condition indicators organized by CMS Certification Number, Home Health Resource Group, and state of service. The new 2014 PUF has information for 10,882 home health agencies, over 6 million claims, and almost $18 billion in Medicare payments. Demographic and chronic condition information is new for this release.


Hospice Quality Measure Reports Available

Two new reports for hospices are available in the Certification and Survey Provider Enhanced Reporting (CASPER) application:

  • Confidential Provider Feedback Reports – Hospice-Level Quality Measure (QM) Report
  • Hospice Patient Stay-Level QM Report

These QM reports allow you to specify a reporting period and view your quality data at both the hospice level and patient-stay level. View the Getting Started with Hospice CASPER QM Reports Fact Sheet and the Requirements and Best Practices webpage for more information.


New ST PEPPER Available

The Short-Term (ST) Program for Evaluating Payment Patterns Electronic Report (PEPPER) with statistics through the third quarter of FY 2016 is available for ST acute care hospitals nationwide. PEPPER files were recently distributed through a QualityNet secure file exchange to hospital QualityNet Administrators and user accounts with the PEPPER recipient role.

PEPPER summarizes hospital-specific data statistics for Medicare severity diagnosis-related groups and discharges at risk for improper payments. It is distributed by TMF® Health Quality Institute under contract with CMS. Visit to access resources, including the user guide, recorded training sessions, information about QualityNet accounts, frequently asked questions, and examples of how other hospitals are using PEPPER.

If you have questions or need help obtaining your report, visit the Help Desk. Send us your feedback or suggestions.


First Two DME Items Subject to Prior Authorization

CMS published a Federal Register Notice announcing the selection of two types of power wheelchairs (K0856 and K0861) that will be subject to required prior authorization. Beginning March 20, 2017, prior authorization will be a condition of payment in New York, Illinois, Missouri, and West Virginia. The requirement will expand nationwide in July 2017.

In December 2015, CMS issued a final rule that established a national prior authorization process as a condition of payment for certain Durable Medical Equipment (DME), Prosthetics, Orthotics, and Supplies (DMEPOS) items that are frequently subject to unnecessary utilization. K0856 and K0861 are the first two items that will be subject to prior authorization under this process.

Visit the Prior Authorization Process for Certain DMEPOS Items webpage for more information.


Part D Prescribers: Date Change and Phased Enforcement

Between now and January 1, 2019, CMS will implement a multifaceted, strategic phased approach that will align enforcement of the Part D prescriber enrollment requirements with other ongoing CMS initiatives. Full enforcement of the Part D prescriber enrollment requirement will begin on January 1, 2019.

CMS encourages all physicians and eligible professionals who prescribe Part D drugs, but are not yet enrolled or validly opted out of Medicare, to enroll in the Medicare Program. Visit the Part D Prescriber Enrollment webpage for more information.


2017 eCQM Logic Flows for Eligible Clinicians Available

CMS published electronic Clinical Quality Measure (eCQM) logic flows for Merit-based Incentive Payment System (MIPS) eligible clinicians on the eCQI Resource Center and eCQM Library websites. The flows for the 2017 performance period assist in interpretation of the eCQM logic and calculation methodology for performance rates. These flows are intended to be used as an additional resource and should not be used in place of the measure specification.

Direct questions about the flows to the ONC CQM Issue Tracker. For more information about MIPS, visit the Quality Payment Program website.


EHR Incentive Programs: Prepare for 2016 Attestation

The attestation system will be open from January 1 to February 28, 2017. For certain measures in the Electronic Health Record (EHR) Incentive Programs final rule, CMS changed the reporting requirements over time to increase flexibility. CMS provided alternative reporting options and exceptions for providers who are:

  • Scheduled to be in an earlier stage of the programs
  • Affected by a significant hardship
  • Implementing or upgrading certified EHR technology

In 2016 there are changes to the following objectives:

  • Secure Electronic Messaging - Eligible Professionals (EPs) only
  • Public Health Reporting

For More Information:


EHR Incentive Programs FAQs on 2017 OPPS/ASC Final Rule

CMS recently added two new FAQs for the Electronic Health Record (EHR) Incentive Programs, providing more information on changes from the CY 2017 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Final Rule:

  • Are new participants that attest only to the Medicaid EHR Incentive Program in 2017 required to attest to Modified Stage 2? See FAQ 18257.
  • What is the policy for measure calculation for actions outside of the EHR reporting period for the Medicare and Medicaid EHR Incentive Programs beginning in 2017? See FAQ 18261.


Provider Compliance


Office of Inspector General Exclusion Authorities

Watch a brief video from the Office of the Inspector General (OIG) and learn about the effect of exclusion authorities. Exclusion is when OIG prevents an individual or an entity from participating in the Medicare, Medicaid, or other Federal health care programs. No program payments will be made for items or services furnished, ordered, or prescribed by the excluded individual or entity. As a result, exclusion can impact your payments, even if you are not the party that is excluded.

This video is part of the OIG Health Care Fraud Prevention and Enforcement Action Team (HEAT) Provider Compliance Training initiative. The video originally aired in 2011, but the information is current.


Claims, Pricers & Codes


Pricing and Payment Changes for DME Infusion Drugs Effective January 1, 2017

For claims with a date of service on or after January 1, 2017, and consistent with Section 5004 of the 21st Century Cures Act, which was signed into law on December 13, 2016, payment for infusion drugs furnished through a covered item of Durable Medical Equipment (DME) will be based on Section 1847A of the Social Security Act, meaning that most of the payments will be based on the Average Sales Price (ASP) of these drugs. Payment for DME infusion drugs that do not appear on the ASP Drug Pricing Files will be determined by the Medicare Administrative Contractors in accordance with the Claims Processing Manual 100-04, Chapter 17, Section 20.1.3.


Upcoming Events


IRF-PAI Therapy Information Data Collection Call — January 12

Thursday, January 12 from 1:30 to 3 pm ET

To register or for more information, visit MLN Connects® Event Registration.

In the fiscal year 2015 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) final rule, CMS finalized a new Therapy Information section on the IRF-Patient Assessment Instrument (PAI).  During this call, CMS will focus on reviewing the types and methods of therapy collected on the IRF-PAI, examples of each type of therapy, and how to accurately code and complete the therapy information section. Prior to the call, participants are encouraged to review the IRF-PAI Training Manual. Participants can also review materials from our 2015 MLN Connects Call  on how to code and complete the new IRF-PAI item for Therapy Data Collection. A question and answer session will follow the presentation.

Target Audience: IRFs.


ESRD QIP: Payment Year 2020 Final Rule Call — January 17

Tuesday, January 17 from 1:30 to 3 pm ET

To register or for more information, visit MLN Connects Event Registration.

Do you participate in the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)? During this call, CMS experts discuss the final rule that operationalizes the ESRD QIP for Payment Year (PY) 2020. The performance period for PY 2020 will begin on January 1, 2018. Take steps now to understand the changes to the program.


  • Legislative framework and how it fits in with CMS strategies to improve quality
  • Changes reflected in the final rule based on public comments
  • Final measures, standards, scoring methodology, and payment reduction scale
  • How the PY 2020 program compares to PY 2019
  • Where to find additional information about the program

Target Audience: Dialysis clinics and organizations; nephrologists; hospitals with dialysis units; billers/coders; and quality improvement experts.


Home Health Groupings Model Technical Report Call — January 18

Wednesday, January 18 from 1:30 to 3 pm ET

To register or for more information, visit MLN Connects Event Registration.

In December 2016, CMS published the Medicare Home Health (HH) Prospective Payment System (PPS): Case-Mix Methodology Refinements technical report, including an overview of the Home Health Groupings Model (HHGM). This technical report describes efforts to reassess the current HH PPS and develop large-scale payment methodology changes. During this call, CMS experts introduce the HHGM model. A question and answer session follows the presentation.

Prior to the call, participants are encouraged to review the technical report.

Target Audience: Home Health Agencies and other interested stakeholders.


Comparative Billing Report Webinar on Knee Orthoses — February 8

Wednesday, February 8 from 3 to 4 pm ET

Join us for an informative discussion of the comparative billing report on Knee Orthoses (CBR201701), an educational tool for suppliers who submit claims for off the shelf and custom fitted prefabricated knee orthoses, also known as knee braces. During the webinar, suppliers will interact directly with content specialists and submit questions about the report. See the announcement for more information and find out how to participate.


Medicare Learning Network® Publications & Multimedia


Continuation of HH Probe and Educate Medical Review Strategy MLN Matters® Article — New

An MLN Matters Special Edition Article on Continuation of the Home Health (HH) Probe and Educate Medical Review Strategy is available. Learn about Round 2 of medical review and reporting.


Dementia Care and QAPI Call: Audio Recording and Transcript — New

An audio recording and transcript are available for the December 6 call on the National Partnership to Improve Dementia Care and Quality Assurance and Performance Improvement (QAPI). Learn about the reform of requirements for long-term care facilities, highlighting the Behavioral Health Services & Pharmacy Services sections. A Tennessee nursing home also discussed innovative approaches to dramatically reduce the use of antipsychotic medications.


ICD-9-CM, ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Code Sets Educational Tool — Revised

A revised ICD-9-CM, ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Code Sets Educational Tool is available. Learn about the code sets and payment information.


Medicare Billing: 837P and Form CMS-1500 Fact Sheet — Revised

A revised Medicare Billing: 837P and Form CMS-1500 Fact Sheet is available. Learn about:

  • Medicare institutional claims submission and coding
  • When Medicare will accept a hard copy claim form
  • Timely filing


DMEPOS Accreditation Fact Sheet — Reminder

The DMEPOS Accreditation Fact Sheet is available. Learn about:

  • Accreditation process for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
  • Accreditation requirement, including the types of exempt providers
  • Resources


MREP Software Fact Sheet — Reminder

The MREP Software Fact Sheet is available. Learn about:

  • Medicare Remit Easy Print (MREP) software overview
  • Benefits of using the electronic remittance advice information
  • Minimum system requirements


Continuing Education Credits for Web-Based Training Courses

Busy clinicians often find it difficult to fit in their required Continuing Medical Education (CME) credits. CMS can help. CMS is accredited by the Accreditation Council for Continuing Medical Education to offer AMA PRA Category 1 Credit™. AMA PRA credit is recognized and accepted by hospital credentialing bodies, state medical licensure boards, and medical specialty certifying boards, as well as other organizations.

Medicare Learning Network web-based training courses carrying CME credit cover a wide variety of topics of interest to clinicians, including:

  • Infection control
  • ICD-10 coding
  • Certificate of medical necessity
  • Provider compliance programs

Visit the WBT webpage for a list of courses offered through the Learning Management and Product Ordering System.



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