- MLN Connects for November 1, 2018
Thursday, November 1, 2018
- HHS Advances Payment Model to Lower Drug Costs for Patients
- SNF Quality Reporting Program Data on Nursing Home Compare
- IRF, LTCH, and SNF Quality Reporting Programs: Submission Deadline November 15
- Hospital Cost Report Data: User-Friendly Version
- Medicare Diabetes Prevention Program: New Covered Service
- November is Home Care and Hospice Month
- Typhoon Yutu and Medicare Disaster Related Commonwealth of the Northern Mariana Islands Claims MLN Matters Article — New
- MRI MLN Matters Article — New
- Incomplete Colonoscopies Billed with Modifier 53 MLN Matters Article — New
- CWF Edit of MA Inpatient Claims from Approved Teaching Hospitals MLN Matters Article — New
- Correction to CWF IUR 7272 for Intervening Stay MLN Matters Article — New
- Redesign of Hospice Periods MLN Matters Article — New
- ASP Medicare Part B Drug Pricing Files and Revisions: January 2019 MLN Matters Article — New
- MCReF System Webcast: Audio Recording and Transcript — New
- Patient Relationship Categories and Codes Webcast: Audio Recording and Transcript — New
- Medicare Podiatry Services Fact Sheet — Revised
- Medicare and Medicaid Basics Booklet — Revised
On October 25, CMS announced and sought input on a new International Pricing Index (IPI) payment model to reduce what Americans pay for prescription drugs. Under the IPI model, described in an Advance Notice of Proposed Rulemaking (ANPRM), Medicare’s payments for select physician-administered drugs would shift to a level more closely aligned with prices in other countries. Overall savings for American taxpayers and patients are projected to total $17.2 billion over five years.
The move from current payment levels to payment levels based on international prices would be phased in over a five-year period, would apply to 50 percent of the country, and would cover most drugs in Medicare Part B, which includes physician-administered medicines. We are considering a randomized approach to determine which areas in the country would participate in the model.
The IPI model would achieve several goals:
- Reduce costs for Medicare beneficiaries, and thereby increase adherence and access to prescription drugs
- Introduce competition to the system of paying for physician-administered drugs by bringing in private-sector vendors
- Reduce providers’ burden and the financial risk associated with managing drug inventories, so physicians can focus on patient care
- Maintain financial stability for physicians, while removing incentives for higher drug prices
- Address the disparity in drug prices between the U.S. and other countries
- Reduce costs to the American taxpayers and Medicare beneficiaries who fund these programs
We will carefully review comments and consider issuing a proposed rule for the IPI in the spring of 2019, with a potential model start in spring 2020. We will accept comments on the ANPRM until December 31.
For More Information:
See the full text of this excerpted HHS Press Release (issued October 25).
CMS announced the first release of Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) quality data on Nursing Home (NH) Compare. NH Compare allows you to find and compare SNFs that are certified by Medicare and nursing homes that are certified by Medicaid. This website contains quality of resident care and staffing information for more than 15,000 nursing homes around the country and will now include SNF QRP quality data that can be used to compare SNF providers.
5 SNF QRP measures are now displayed on NH Compare:
- Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short Stay) (National Quality Forum #0678)
- Application of Percent of Long-Term Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)
- Application of Percent of Residents Experiencing One or More Falls with Major Injury (NQF #0674)
- Medicare Spending Per Beneficiary-PAC SNF QRP
- Discharge to Community-PAC SNF QRP
The submission deadline for the Inpatient Rehabilitation Facility (IRF), Long-Term Care Hospital (LTCH), and Skilled Nursing Facility (SNF) Quality Reporting Programs for the second quarter of 2018 is 1:59 pm PT on November 15.
For More Information:
- IRF Quality Reporting Data Submission Deadlines webpage
- LTCH Quality Reporting Data Submission Deadlines webpage
- SNF Quality Reporting Program Data Submission Deadlines webpage
CMS developed a user-friendly version of the Hospital Cost Report Public Use File (PUF) for 2014 in a simplified Excel format. The PUF includes information for 6,248 facilities, including all hospital facility types and all payers. It covers 33 million discharges, 180 million days, $876 billion in net revenue, and $889 billion in operating expenses. Visit the Hospital Cost Report PUF webpage for more information.
November is National Diabetes Month. The 2019 Medicare & You Handbook includes information on the Medicare Diabetes Prevention Program (MDPP), a new Medicare-covered service. Help your patients prevent or delay Type 2 diabetes and understand their treatment options.
For More Information:
- Review materials from the September 26 Medicare Learning Network call and the beneficiary brochure
- Become familiar with beneficiary eligibility criteria and coverage; screen at-risk patients for eligibility
- Access the MDPP Supplier Map or view a list of all current MDPP suppliers; refer eligible patients to a nearby MDPP supplier
- Visit the MDPP Expanded Model webpage
MDPP is a new program that is still ramping up. If you do not see an organization that offers services in your community, keep checking the list. New MDPP suppliers are added to the list on a regular basis.
Did you know that Medicare covers a wide range of health care services that can be provided in the home to treat an illness or injury for homebound beneficiaries who require skilled services? In addition, hospice care empowers people with life-limiting illnesses to remain at home, surrounded and supported by family and loved ones at the end of life. Talk to your Medicare patients about appropriate home care and hospice services.
For More Information:
- Home Health Prospective Payment System Fact Sheet
- Medicare Home Health Benefit Fact Sheet
- Medicare Home Health Benefit Web-Based Training course: Available through the Learning Management System - Opens in a new window
- Hospice Payment System Fact Sheet
The Office of the Inspector General (OIG) reports that Medicare is vulnerable to fraud, waste, and abuse for wet Age-related Macular Degeneration (wet AMD) and cataracts:
- Administration of Lucentis injections for wet AMD more than once every 28 days (based on local coverage determinations)
- Billing for a second cataract surgery on the same eye
- Submitting disproportionately more claims for complex than standard cataract surgery
Review the following resources for proper claims coding, billing, and payment:
- Questionable Billing for Medicare Ophthalmology Services OIG Report, September 2015
- Medicare Paid $22 Million in 2012 for Potentially Inappropriate Ophthalmology Claims OIG Report, December 2014
- Cataract Removal, Part B MLN Matters® Special Edition Article
- Implementation of CMS Ruling Regarding Presbyopia-Correcting Intraocular Lenses for Medicare Beneficiaries MLN Matters Article
- Multiple Procedure Payment Reduction on the Technical Component of Diagnostic Cardiovascular and Ophthalmology Procedures MLN Matters Article
- Medicare Vision Services Fact Sheet
- NCCI Policy Manual for Medicare Services, Chapter 8: Section D: Ophthalmology
- Medicare National Coverage Determinations Manual, Part 1: Section 10.1: Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery
- Medicare Benefit Policy Manual, Chapter 15: Section 120: Prosthetic Devices and Section 260.2: Ambulatory Surgical Center Services
Thursday, November 15 from 1:30 to 3 pm ET
Register - Opens in a new window for Medicare Learning Network events.
During this call, learn about changes finalized in the FY 2019 Inpatient Rehabilitation Facility (IRF) Prospective Payment System final rule, including:
- Revisions to coverage criteria
- Removal of the Functional Independence Measure (FIM™) and Associated Function Modifiers from the IRF - Patient Assessment Instrument
- Refinements to the case mix classification
Prior to the call, participants are encouraged to review the Medicare Benefit Policy Manual, Chapter 1, Section 110. A question and answer session follows the presentation; however, attendees may email questions in advance to firstname.lastname@example.org with “November 15 Call” in the subject line. These questions may be addressed during the call or used for other materials following the call.
Target Audience: IRF providers.
Typhoon Yutu and Medicare Disaster Related Commonwealth of the Northern Mariana Islands Claims MLN Matters Article — New
The President declared a state of emergency for the Commonwealth of the Northern Mariana Islands, and the HHS Secretary declared a Public Health Emergency, which allows for CMS programmatic waivers based on Section 1135 of the Social Security Act. An MLN Matters Special Edition Article on Typhoon Yutu and Medicare Disaster Related Commonwealth of the Northern Mariana Islands Claims is available. Learn about blanket waivers CMS issued for the impacted geographical areas. These waivers will prevent gaps in access to care for beneficiaries impacted by the emergency.
A new MLN Matters Article MM10877 on Magnetic Resonance Imaging (MRI) is available. Learn about allowable line items.
A new MLN Matters Article MM10937 on Incomplete Colonoscopies Billed with Modifier 53 for Critical Access Hospital (CAH) Method II Providers is available. Learn about payment methodology for incomplete procedures.
A new MLN Matters Article MM10959 on Update to Common Working File (CWF) Edit of Medicare Advantage (MA) Enrollees' Inpatient Claims from Approved Teaching Hospitals Billed for Indirect Medical Education is available. Learn about bypassing edit 5233.
A new MLN Matters Article MM10960 on Correction to Common Working File (CWF) Informational Unsolicited Response (IUR) 7272 for Intervening Stay is available. Learn about bypassing an edit.
A new MLN Matters Article MM10967 on Redesign of Hospice Periods – Additional Requirements is available. Learn about claim submission instructions and revised Chapter 11 of the Medicare Claims Processing Manual.
A new MLN Matters Article MM11016 on January 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files is available. Learn about the drug pricing files used to determine the payment limit for claims.
An audio recording and transcript are available for the October 15 webcast on Submitting Your Medicare Part A Cost Report Electronically. Learn how to use the new Medicare Cost Report e-Filing (MCReF) system.
An audio recording and transcript are available for the October 17 webcast on Patient Relationship Categories and Codes. Receive guidance for classifying patient relationships during the voluntary reporting period that CMS implemented on January 1, 2018.
A revised Medicare Podiatry Services Fact Sheet is available. Learn covered foot care service requirements, exclusions from coverage, and foot care for patients with chronic disease.
A revised Medicare and Medicaid Basics Booklet is available. Learn quick facts, covered services, and other types of common coverage.
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