MLN Connects for September 28,2017

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Thursday, September 28, 2017

News & Announcements

Provider Compliance

Claims, Pricers & Codes

Upcoming Events

Medicare Learning Network Publications & Multimedia

View this edition as a PDF (PDF)  



News & Announcements 


Medicare Clinical Laboratory Fee Schedule: Preliminary CY 2018 Payment Rates

On September 22, CMS published preliminary payment rates with the supporting data files as part of the implementation of Section 216 of the Protecting Access to Medicare Act of 2014. This section requires clinical laboratories to report how much private insurers pay for lab tests. The new private payor rate-based Clinical Lab Fee Schedule (CLFS) will go into effect on January 1, 2018.  CMS worked closely with stakeholders to gather the necessary data in the least burdensome manner possible. As a result of these efforts, the data reported to CMS captures over 96% of laboratory tests on the CLFS, representing over 96% of Medicare’s spending on tests in CY 2016. Laboratories from every state, the District of Columbia, and Puerto Rico reported data.

Send comments on the preliminary determinations by October 23 to .

For More Information:


2016 PQRS Feedback Reports and Annual QRURs Updates

You can now look up your current and prior years’ Value Modifier and PQRS payment adjustments, and find out which feedback reports are available for your practice (Annual, Mid-Year and Supplemental QRURs, PQRS Feedback Reports). View the “.


The 2018 PQRS and Value Modifier payment adjustments shown in the 2016 reports are based on proposals included in the 2018 Medicare Physician Fee Schedule Proposed Rule. We will notify practices if there is a change in their PQRS or Value Modifier payment adjustments based on policies in the final rule. The 2018 proposals included:

  • Reducing by half the automatic downward Value Modifier payment adjustment for practices that did not meet the minimum quality reporting requirements
  • Holding all practices that met the minimum quality reporting requirements harmless from downward Value Modifier payment adjustments
  • Reducing the maximum upward Value Modifier payment adjustment for performance for large practices to align with the adjustment for small and solo practices 
  • Reducing the number of measures that must be satisfactorily reported for the 2016 PQRS to avoid the 2018 downward payment adjustment from 9 measures across 3 National Quality Strategy domains to 6 measures with no domain requirement  

If the policies are not finalized as proposed, we will provide an update to report recipients.

For more information see last week’s message.


Quality Payment Program: New Resources Available

CMS posted new and updated resources on the Quality Payment Program:

Additional resources are available on the Resource Library webpage.


Quality Payment Program: View Recordings of Recent Webinars

Unable to participate in a recent Quality Payment Program (QPP) webinar? View all recordings, presentations, and transcripts on the webpage. Recent webinars:

  • August 16: QPP Notice of Proposed Rulemaking Office Hours Session – Detailed overview on the draft provisions; see from this session
  • August 30: 2018 Self Nomination Process for Qualified Clinical Data Registries (QCDRs) and Qualified Registries – Overview of the 2018 self-nomination process for organizations that wish to become QCDRs and qualified registries for the Merit-based Incentive Payment System (MIPS) for the 2018 performance period
  • September 8: Overview of MIPS for Small, Rural, and Underserved Practices – Overview of MIPS, the flexibilities for small practices under MIPS, and the resources offered by Technical Assistance organizations

For More Information:

  • Visit the QPP website
  • Contact the QPP Service Center at 866-288-8292 (TTY 877-715- 6222) or


MIPS Eligible Measure Applicability: New Resources Available

Learn about the Eligible Measure Applicability (EMA) analysis for the Merit-based Incentive Payment System (MIPS) and how it affects your quality performance calculation and score:

For questions about EMA, contact the Quality Payment Program at 866-288-8292 (TTY 877-715-6222) or .


National Cholesterol Education Month and World Heart Day

September is National Cholesterol Education Month, and September 29is World Heart Day. These observances raise awareness about cardiovascular disease, cholesterol, and stroke. Talk to your patients about appropriate Medicare-covered services and screenings.

For More Information:

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


Provider Compliance


Psychiatry and Psychotherapy CMS Provider Minute Video — Reminder

Proper payment and sufficient documentation go hand in hand. The CMS Provider Minute: Psychiatry and Psychotherapy video includes pointers to properly submit documentation for these services. Learn about:

  • Use of add-on codes when billing for same day evaluation and management and psychotherapy services
  • Three factors needed for sufficient documentation

This video is part of a series to help providers of all types improve in areas identified with a high degree of noncompliance.


Claims, Pricers & Codes


Clinicians: Medicare Part B Crossover Claims Issue Tied to Error Code H51082

In recent weeks, you may have received a notice from your Medicare Administrative Contractor (MAC) containing error code H51082—“The ICD-10 code (e.g., ‘ M4806') must be coded to the highest specificity.”  The notice indicated that the claims listed could not be crossed over due to claim data errors. Most of the Part B claims that received the H51082 code were rejected in error; the ICD-10 diagnosis codes that received the H51082 were still valid through September 30, 2017. On September 20, CMS asked the MACs to repair these claims and resend them to the Benefits Coordination & Recovery Center. Direct your vendors not to bill your patients’ supplemental insurers for balances remaining until October 6 to allow the claims to be crossed over. 


Upcoming Events


Home Health Agencies: Quality of Patient Care Star Rating Algorithm Call — October 10

Tuesday, October 10 from 2-3 pm ET

Register for Medicare Learning Network events.

During this call, learn about modifications and proposed changes to the way the Quality of Patient Care star rating is calculated, including the removal of the influenza measure. CMS presents the rationale, proposed timing, and impact of the changes. A question and answer session follows the presentation.

Target Audience: Medicare-certified Home Health Agencies.


2016 Annual QRURs Webcast — October 19

Thursday, October 19 from 1:30 to 3 pm ET

Register for Medicare Learning Network events.

2016 Annual Quality and Resource Use Reports (QRURs) are available for all group practices and solo practitioners nationwide. This event provides an overview of the report and explains how to interpret and use the information.

2016 Annual QRURs show how groups and solo practitioners performed in 2016 on the quality and cost measures used to calculate the 2018 Value-Based Payment Modifier (Value Modifier) and how the Value Modifier will be applied to payments for physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. Learn more on the 2016 QRUR and 2018 Value Modifier webpage. This event will be more meaningful if you have your report in front of you to follow along. Visit to access your report prior to the event.


  • Overview of the 2018 Value Modifier and 2016 Annual QRUR
  • Information in the 2016 Annual QRUR and accompanying tables
  • How to access the 2016 Annual QRUR
  • How to request an informal review of your 2018 Value Modifier

CMS will use webcast technology for this event with audio streamed through your computer. Please note: if you are unable to stream audio through your computer, phone lines are available.

This event is being evaluated by CMS for CME and CEU continuing education credit (CE). Check the webpage for CE Activity Information & Instructions.

Target Audience: Physicians, Medicare eligible professionals, medical group practices, practice managers, medical and specialty societies.


Medicare Learning Network Publications & Multimedia


2017-2018 Influenza Resources for Health Care Professionals MLN Matters® Article — New

An MLN Matters Special Edition Article on 2017-2018 Influenza (Flu) Resources for Health Care Professionals (PDF) is available. Learn about codes and payment rates for influenza and pneumococcal vaccines.


Billing in Medicare Secondary Payer Liability Insurance Situations MLN Matters Article — New

An MLN Matters Special Edition Article on Billing in Medicare Secondary Payer (MSP) Liability Insurance Situations (PDF) is available. Learn about fundamentals of billing when liability insurance (including self-insurance) is involved.


Accepting Payment from Patients with Set-Aside Arrangements MLN Matters Article — New

An MLN Matters Special Edition Article on Accepting Payment from Patients with a Workers' Compensation Medicare Set-Aside Arrangement, a Liability Insurance Medicare Set-Aside Arrangement, or a No-Fault Insurance Medicare Set-Aside Arrangement (PDF) is available. Learn about Medicare Set-Aside Arrangements and why it is appropriate to accept payment from a patient that has a funded Medicare Set-Aside Arrangement.


Clarification of Billing and Payment Policies for Negative Pressure Wound Therapy Using a Disposable Device MLN Matters Article — New

An MLN Matters Special Edition Article on Clarification of Billing and Payment Policies for Negative Pressure Wound Therapy Using a Disposable Device (PDF) is available. Learn about billing and payment for this service under a home health plan of care.


Transition to New Medicare Numbers and Cards Fact Sheet — New

A new Transition to New Medicare Numbers and Cards Fact Sheet is available. Learn about:

  • Why CMS is issuing new Medicare numbers and cards
  • What you need to do to get ready for the change
  • Where to find help


Nursing Home Call: Audio Recording and Transcript — New

An , transcript (PDF), and clarification (PDF) are available for the call for nursing homes. Learn about the new Facility Assessment Tool to help identify and develop the specific assessment of your facility. Also, find out about frequently asked questions related to revision of the State Operations Manual Appendix PP.


SNF Consolidated Billing Web-Based Training Course — Reminder

With Continuing Education Credit

The Skilled Nursing Facility (SNF) Consolidated Billing Web-Based Training (WBT) course is available through the Learning Management System. Learn about:

  • Payment information for services provided in a Medicare-covered SNF stay, including most services provided by entities other than the SNF
  • Bundled prospective payments made through the Fiscal Intermediary or Medicare Administrative Contractor


Remittance Advice Resources and FAQs Fact Sheet — Reminder

The Fact Sheet is available. Learn about:

  • Standard paper remittance vs Electronic Remittance Advice (ERA)
  • Enrolling in ERA
  • Free Medicare ERA software
  • Commercial ERA software


Medicare Enrollment Guidelines for Ordering/Referring Providers Booklet — Reminder

The Booklet is available. Learn about:

  • Three basic requirements for ordering and referring
  • How to enroll in Medicare as an ordering/referring provider



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