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MLN Connects for January 19, 2017

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Thursday, January 19, 2017

News & Announcements

Provider Compliance

Claims, Pricers & Codes

Upcoming Events

Medicare Learning Network Publications & Multimedia

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News & Announcements


Over 40 Million Medicare Beneficiaries Utilized Free Preventive Services in 2016

On January 13, HHS released new information that shows that millions of seniors and people with disabilities with Medicare continue see improved benefits in 2016 as a result of the Affordable Care Act. Medicare beneficiaries continue to take advantage of certain recommended preventive services with no coinsurance:

  • An estimated 40.1 million people with Medicare (including those enrolled in Medicare Advantage) took advantage of at least one preventive service with no copays or deductibles in 2016, slightly more than in 2015.
  • More than 10.3 million Medicare beneficiaries (including those enrolled in Medicare Advantage) took advantage of an Annual Wellness Visit in 2016. Looking just at original Medicare, nearly one million more people utilized an Annual Wellness Visit in 2016 than 2015 (more than 6.6 million compared to nearly 5.8 million).

View state-by-state information on utilization. See the full text of this excerpted CMS Press Release (issued January 13).


Prosthetics and Custom‑Fabricated Orthotics Practitioners and Suppliers: Establishment of Special Payment Provisions and Requirements

CMS issued a proposed rule that would implement statutory requirements and specify:

  • Qualifications needed for qualified practitioners to furnish and fabricate prosthetics and custom-fabricated orthotics and for qualified suppliers to fabricate prosthetics and custom-fabricated orthotics
  • Accreditation requirements that qualified suppliers must meet in order to bill
  • Requirements that an organization must meet in order to accredit qualified suppliers
  • Timeframe by which qualified practitioners and suppliers must meet the applicable licensure, certification, and accreditation requirements

This rule would also remove the exemption from quality standards and accreditation that is currently in place in accordance with section 1834(a)(20) of the Act for certain practitioners and suppliers. In addition, this rule also includes authority for CMS to revoke the Medicare enrollment of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers that submit claims for items that do not meet the requirements of the statute and this proposed rule.

CMS will accept comments on the proposed rule until March 13 and will respond to comments in a final rule. See the full text of this excerpted CMS Fact Sheet (issued January 11).


eCQM Data: Extension of 2016 Reporting Deadline to March 13

CMS is notifying eligible hospitals and critical access hospitals participating in the Hospital Inpatient Quality Reporting (IQR) and/or the Medicare Electronic Health Record (EHR) Incentive Programs of a deadline extension to March 13. The extension is for the submission of electronic Clinical Quality Measure (eCQM) data for the 2016 reporting period, pertaining to the FY 2018 payment determination.  

We intend to include proposals regarding the 2017 eCQM reporting requirements in the FY 2018 Inpatient Prospective Payment System proposed rule that we anticipate to be published in late spring. Specifically, we plan to address:

  • Stakeholder concerns regarding challenges associated with hospitals transitioning to new EHR systems or products
  • Upgrading to EHR technology certified to the 2015 Edition, modifying workflows, and addressing data element mapping
  • The time allotted for hospitals to incorporate updates to eCQM specifications in 2017. 

For more information about eCQM reporting, please visit the QualityNet and EHR Incentive Programs websites. See the full text of this excerpted CMS Blog (issued January 17).


EHR Incentive Program: Attest to 2016 Program Requirements by February 28 

The Registration and Attestation System is now open. Providers participating in the Medicare Electronic Health Record (EHR) Incentive Program must attest to the 2016 program requirements by February 28 to avoid a 2018 payment adjustment.

  • The EHR reporting period is any continuous 90 days between January 1 and December 31, 2016.
  • If you are participating in the Medicaid EHR Incentive Program, please refer to your state’s deadlines for attestation information.
  • If you are eligible to participate in both the Medicare and Medicaid EHR Incentive Programs, you must demonstrate meaningful use to avoid the Medicare payment adjustment. You may demonstrate meaningful use under either Medicare or Medicaid.


For questions, contact the EHR Information Center at 888-734-6433 (press option 1).


EHR Incentive Programs: Calculations for Objectives and Measures Requiring Patient Action

CMS recently updated an FAQ to provide information about calculations for EHR Incentive Programs objectives and measures requiring patient action:

  • Question: In calculating the meaningful use objectives requiring patient action, if a patient sends a message or accesses his/her health information made available by their eligible professional (EP), can the other EPs in the practice get credit for the patient’s action in meeting the objectives?
  • Answer: See FAQ 12825.


CMS Releases ESRD QIP Performance Score Reports for PY 2017

CMS released End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) Payment Year (PY) 2017 Final Performance Score Reports (PSRs) for outpatient dialysis facilities. This PSR finalizes your facility’s performance, including any revisions from the Preview Period. In addition, PY 2017 performance and payment-reduction information for all facilities is posted on Dialysis Facility Compare and the ESRD QIP website. To retrieve your Final PSR and Performance Score Certificates, access your account via QualityNet. For questions about the Final PSR or the program, contact


New Care Management Webpage

A Care Management webpage is now available on the Physician Fee Schedule website. This new webpage includes fact sheets, FAQs, and other information on chronic care management, transitional care management, and similar services under the Medicare physician fee schedule. Bookmark the new webpage and check back often for new content.


Provider Enrollment Application Fee Amount for CY 2017

On November 7, CMS issued a notice: Provider Enrollment Application Fee Amount for Calendar Year 2017 [CMS–6071–N]. Effective January 1, 2017, the CY 2017 application fee is $560 for institutional providers that are:

  • Initially enrolling in the Medicare or Medicaid program or the Children's Health Insurance Program (CHIP);
  • Revalidating their Medicare, Medicaid, or CHIP enrollment; or
  • Adding a new Medicare practice location.

This fee is required with any enrollment application submitted from January 1, 2017, through December 31, 2017.


2017 Annual Stationary Oxygen Budget Neutrality Calculations  

CMS posted the calculations of the percentage reduction in the 2017 fee schedule amounts for stationary oxygen equipment. These changes ensure budget neutrality of the oxygen payment classes added in 2007. The calculations are available on the Durable Medical Equipment Fee Schedule webpage.


Glaucoma Awareness Month: Make a Resolution for Healthy Vision

Encourage people at higher risk for glaucoma to make a resolution for healthy vision this New Year. Medicare provides glaucoma screening coverage for beneficiaries in at least one high risk group; recommend an annual screening if appropriate.

For More Information:

Visit the Preventive Services website to learn more about Medicare-covered services.


Provider Compliance


Hospice Election Statements Lack Required Information or Have Other Vulnerabilities

After a stratified random sample review of hospice election statements and certifications of terminal illness, the Office of the Inspector General (OIG) reports that more than one-third of hospice General Inpatient (GIP) stays lack required information or had other vulnerabilities.

  • Hospice election statements did not always mention – as required – that the beneficiary was waiving coverage of certain Medicare services by electing hospice care or that hospice care is palliative rather than curative
  • In 14 percent of GIP stays, the physician did not meet requirements when certifying that the beneficiary was terminally ill and appeared to have limited involvement in determining that the beneficiary’s condition was appropriate for hospice care

Hospices should improve their election statements and ensure that physicians meet requirements when certifying beneficiaries for hospice care. Resources:


Claims, Pricers & Codes


OPPS Hospital Claim Issues

Due to errors in the Medicare Claims Processing System, some Outpatient Prospective Payment System (OPPS) hospital claims with dates of service on or after January 1, 2017, may be overpaid. Claims with the following HCPCS codes may be impacted: 0253T, 0335T, 24361, 25420, 25444, 25445, 27442, 27871, 28715, 28730, 37229, 43266, 45389, 62360, 64580, 69717, and 75898.

In addition, eight Comprehensive Ambulatory Payment Classification (APC) Complexity Adjustment pairs were incorrectly omitted from the claims processing system:

            Primary Code:            Code 2:                       Complexity-Adjusted APC:

            28300                          27698                          5115

            28300                          28306                          5115

            33208                          C9600                         5224

            36902                          36908                          5193

            36903                          36908                          5194

            36904                          36908                          5193

            36905                          36908                          5194

            49653                          49650                          5362

A correction for these issues will be implemented on April 3. Medicare Administrative Contractors will automatically reprocess impacted claims. Providers do not need to take any action.       

NCCI Edits for Institutional and Physician Claims:

National Correct Coding Initiative (NCCI) edit updates for institutional claims have regularly been implemented one quarter behind the physician claim NCCI edits due to systems issues. As a result, some physician single quarter only edits were not implemented for institutional claims. Starting April 3, CMS will apply the same physician NCCI edits to institutional claims, including the single quarter only edits.


Upcoming Events


Medicare Quality Programs: Transitioning from PQRS to MIPS Call — January 24

Tuesday, January 24 from 2 to 3:30 pm ET

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

During this call, find out how to complete the final reporting period for the legacy Medicare quality reporting programs and transition to the Merit-based Incentive Payment System (MIPS). A question and answer session follows the presentation.



  • Wrapping Up the 2016 Program Year for the Physician Quality Reporting System (PQRS), Medicare Electronic Health Record (EHR) Incentive Program, and Value-Based Payment Modifier (VM)
  • Transitioning to MIPS  
  • Timeline for PQRS, EHR, VM, and MIPS programs with submission timeframes and other key milestones
  • Resources

Target Audience: Physicians, Accountable Care Organizations; Medicare eligible professionals; therapists; medical group practices; practice managers; medical and specialty societies; payers; and insurers.

This MLN Connects Call is being evaluated by CMS for CME and CEU continuing education credit (CE). Refer to the call detail page for more information.


Medicare Learning Network Publications & Multimedia


Medicare Quarterly Provider Compliance Newsletter [Volume 7, Issue 2] — New

A new Medicare Quarterly Provider Compliance Newsletter [Volume 7, Issue 2] Educational Tool is available. Learn about:

  • How to avoid common billing errors and other erroneous activities
  • How to address and avoid the top issues this quarter


Medicare Parts C and D General Compliance Web-Based Training Course — Revised

A revised Medicare Parts C and D General Compliance Web-Based Training course is available through the Learning Management and Product Ordering System. Learn about:

  • How compliance programs operate
  • Reporting compliance program violations


Combating Medicare Parts C and D Fraud, Waste, and Abuse Web-Based Training Course — Revised

A revised Combating Medicare Parts C and D Fraud, Waste, and Abuse Web-Based Training course is available through the Learning Management and Product Ordering System. Learn about:

  • Major laws and regulations
  • How to recognize fraud, waste, and abuse
  • Potential consequences and penalties for violations
  • Preventing, reporting, and correcting fraud, waste, and abuse


Health Care Professional Frequently Used Web Pages Educational Tool — Revised

A revised Health Care Professional Frequently Used Web Pages Educational Tool is available. Learn about:

  • Coverage
  • Billing and payment
  • Medicare contracting


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

The ICD-9-CM, ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Code Sets Educational Tool is available. Learn about definitions and payment information for these code sets.


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