Why I should use the MBI now
Starting January 1, 2020, even for services provided before this date, you must use MBIs
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How I know my patient is eligible through the railroad board
What to do if an MBI changes

Protect your patients’ identities, and use the MBI now. Starting January 1, 2020, you must use MBIs regardless of the date of service:

We will reject claims you submit with Health Insurance Claim Numbers (HICNs) with a few exceptions
We will reject all eligibility transactions you submit with HICNs

Don’t have an MBI?

Ask your patients for their cards. If they did not get a new card, give them the Get Your New Medicare Card flyer in English (PDF) or Spanish (PDF).
Use your Medicare Administrative Contractor’s look-up tool. Sign up (PDF) for the Portal to use the tool.
Check the remittance advice. We return the MBI on the remittance advice for every claim with a valid and active HICN.

Quality Payment Program: Submit Comments on 2020 Proposed Rule by September 27

CMS released proposed policies for the 2020 performance year of the Quality Payment Program via the Medicare Physician Fee Schedule proposed rule. We are seeking comment on a variety of proposals, including the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs). Submit comments by September 27.

For More Information:

SNF PPS Patient Driven Payment Model: Get Ready for Implementation on October 1

On October 1, the new Patient Driven Payment Model (PDPM) is replacing the Resource Utilization Group, Version IV (RUG-IV) for the Skilled Nursing Facility (SNF) Prospective Payment System (PPS). PDPM improves the accuracy and appropriateness of payments by classifying patients into payment groups based on specific, data-driven patient characteristics, while simultaneously reducing administrative burden.

Changes to the Assessment:

Both RUG-IV and PDPM use the Minimum Data Set (MDS) 3.0 as the basis for patient assessment and classification, but the assessment schedule under PDPM is more streamlined and less burdensome on providers. See the presentation (PDF) (starting on slide 52) to find out how your assessments will change.

Billing for Services:

Use the Health Insurance Prospective Payment System (HIPPS) code generated from assessments with an assessment reference date on or after October 1, 2019, to bill under the PDPM.

Changes to Payment:

Under the PDPM, clinically relevant factors and patient characteristics are used to assign patients into case-mix groups across the payment components to derive payment. Additionally, the PDPM adjusts per diem payments to reflect varying costs throughout the stay.

CMS has resources to help you prepare:

PDPM webpage, including fact sheets, FAQs, presentation (PDF), and coding crosswalks/classification logic
Videos: PDPM: What Is Changing (and What Is Not) - Opens in a new window and Integrated Coding & PDPM Case Study - Opens in a new window
from the Medicare Learning Network call in December
Implementation of the SNF PDPM (PDF) MLN Matters Article
New Medicare Webpage on PDPM (PDF) MLN Matters Article

2019 QRDA I Implementation Guide and Sample File for Hospital Quality Reporting: Updated

CMS updated the 2019 Quality Reporting Document Architecture (QRDA) Category I Implementation Guide and sample file to include additional guidance on reason template placement (new appendix in section 9 of the Implementation Guide) and emphasize the change to not include value set object identifiers. The Implementation Guide outlines requirements for eligible hospitals and critical access hospitals reporting electronic clinical quality measures for the:

Hospital Inpatient Quality Reporting Program
Medicare and Medicaid Promoting Interoperability Programs

For More Information:

Implementation Guide Changes for CY 2019 - Opens in a new window webinar
QRDA webpage
Submit questions to the QRDA Project Tracking System

Post-Acute Care and Hospice Utilization and Payment Public Use Files

CMS posted the first annual release of the Post-Acute Care (PAC) and hospice utilization and payment Public Use Files (PUFs) with data for 2017. These PUFs replace the home health, hospice, and Skilled Nursing Facilities (SNFs) utilization and payment PUFs released in past years. Improvements include:

Data for Inpatient rehabilitation Facilities (IRFs) and Long-Term Care Hospitals (LTCHs)
New metrics
Standardized metrics across all PAC and hospice settings

These PUFs include:

Summarized information on services provided to Medicare beneficiaries by 9,701 home health agencies, 4,254 hospices, 15,036 SNFs, 1,119 IRFs, and 410 LTCHs
Summarized information on nearly 16 million claims and over $74 billion in Medicare payments
Demographic and clinical characteristics of beneficiaries served; professional and paraprofessional service utilization; submitted charges; and payments at the provider, state, and national levels
Payment information at the payment system level for home health agencies, SNFs, and IRFs

Clinical Diagnostic Laboratories: Resources about the Private Payor Rate-Based CLFS

The Protecting Access to Medicare Act of 2014 (PAMA) required significant changes to how Medicare pays for clinical diagnostic laboratory tests under the Clinical Laboratory Fee Schedule (CLFS). Effective January 1, 2018, the payment amount for most tests equals the weighted median of private payor rates. Payment rates under the private payor rate-based CLFS are updated every three years.

If you are a laboratory, including an independent laboratory, a physician office laboratory, or hospital outreach laboratory that meets the definition of an applicable laboratory, you are required to report information, including laboratory test HCPCS codes, associated private payor rates, and volume data.

Learn more by reading:

Summary (PDF): Overview of key terms and concepts and how to determine whether your laboratory is an applicable laboratory
MLN Matters Article (PDF): Detailed information and examples to help you determine if you need to report
FAQs (PDF): Responses to questions regarding the changes effective January 1

If you meet the applicable laboratory criteria, act now using this schedule:

January – June, 2019: Collect data
July – December, 2019: Analyze data
January – March, 2020: Report data

For more information, review the from the January 22 Medicare Learning Network call and the PAMA Regulations webpage.

Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier

Medicare pays Medicare Diabetes Prevention Program (MDPP) suppliers to furnish group-based intervention to at-risk Medicare beneficiaries:

Centers for Disease Control and Prevention (CDC)-approved National Diabetes Prevention Program curriculum
Up to 2 years of sessions delivered to groups of eligible beneficiaries

Find out how to become a Medicare enrolled MDPP supplier:

Obtain CDC preliminary or full recognition: Takes at least 12 months to obtain preliminary recognition and up to 24 additional months to achieve full recognition; see the Supplier Fact Sheet and CDC website for more information
Prepare for Medicare enrollment; see the Enrollment Fact Sheet and Checklist
Apply (PDF) to become a Medicare enrolled MDPP supplier (existing Medicare providers must re-enroll), See the Enrollment Webinar Recording and Enrollment Tutorial Video - Opens in a new window
Furnish MDPP services; see the Session Journey Map
Submit claims to Medicare; view the Billing and Claims Webinar Recording; see the Billing and Claims Fact Sheet and Billing and Payment Quick Reference Guide

For More Information:

MDPP Expanded Model (PDF) Booklet
from Medicare Learning Network call on June 20, 2018
MDPP webpage
CDC - CMS Roles Fact Sheet
Contact the MDPP Help Desk at

Hospice Quality Reporting Program Quarterly Updates

Sign up for quarterly email updates about the Hospice Quality Reporting Program (HQRP): Send your facility name, CMS Certification Number, and any new or updated email addresses to .

View the September Update (PDF)
Find past issues on the HQRP Requirements and Best Practices webpage

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:

Educational Tool
National Cholesterol Education Month website, Centers for Disease Control and Prevention
World Heart Day - Opens in a new window website
Million Hearts®: An HHS initiative to improve cardiovascular health

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

Compliance

DME Proof of Delivery Documentation Requirements

CMS simplified and clarified documentation requirements for proof of delivery of Durable Medical Equipment (DME) and related services. If you are a physician, provider, or supplier who bills a DME Medicare Administrative Contractor, read the MLN Matters Article on Proof of Delivery Documentation Requirements (PDF) for details. Learn about updates to support compliance and the impact on your payment.

More resources to help you bill correctly and avoid overpayment recoveries:

Medicare Program Integrity Manual, Chapter 4 (PDF), Section 26
42 CFR Section 424.57(c)(12)

Claims, Pricers & Codes

Medicare Diabetes Prevention Program: Valid Claims

For a claim to be valid under the Medicare Diabetes Prevention Program (MDPP), you must have both:

Centers for Disease Control and Prevention (CDC) preliminary or full recognition; see the Supplier Fact Sheet and CDC website for more information
Separate Medicare enrollment as an MDPP supplier (Specialty D1); see the Enrollment Fact Sheet and Checklist

Important:

If you do not have a separate Medicare enrollment as an MDPP supplier and you submit a claim for MDPP services, your claim will be rejected.

Medicare enrolled MDPP suppliers: See the Quick Reference Guide to Payment and Billing and the Billing and Claims Fact Sheet for information on valid claims:

MDPP Medicare beneficiary eligibility data is returned via the HIPAA Eligibility Transaction System (HETS) on the 271 response; use this data to determine if a beneficiary meets the criteria to receive MDPP services
Submit claims when a performance goal is met, and report codes only once per eligible beneficiary (except G9890 and G9891)
List each HCPCS code with the corresponding session date of service and the coach’s National Provider Identifier (NPI)
List all HCPCS codes associated with a performance payment (including non-payable codes) on the same claim
Include Demo code 82 in block 19 (Loop 2300 segment REF01 (P4) and segment REF02 (82)) to identify MDPP services
Do not include codes for other, non-MDPP services on the same claim

Trouble with MDPP billing and claims:

Some MDPP claims are being denied as a result of a systems issue
Medicare Administrative Contractors (MACs) are manually processing these claims through October 2019 until the fix is implemented
Contact your MAC with questions

For More Information:

MDPP Expanded Model (PDF) Booklet
MDPP webpage

Events

IRF/LTCH: Reporting Health Care Personnel Influenza Vaccination Data Webinars — October 1, 3, or 9

The Centers for Disease Control and Prevention invites Inpatient Rehabilitation Facilities (IRFs) and Long-Term Care Hospitals (LTCHs) to attend refresher training on reporting health care personnel influenza vaccination summary data to the National Healthcare Safety Network.

IRF: Tuesday, October 1 from 2 to 3 pm or Wednesday, October 9 from 11:30 am to 12:30 pm ET
LTCH: Thursday, October 3 from 12:30 to 1:30 pm ET

Note: The reporting requirements have not changed from last year’s influenza season. Send reporting questions to and include “HPS Flu Summary” and your facility type in the subject line.

MLN Matters® Articles

Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) - January 2020

A new MLN Matters Article MM11462 on Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) – January 2020 (PDF) is available. Learn about changes to the HCPCS, ZIP code, and supplier files.

October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files — Revised

A revised MLN Matters Article MM11343 on October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files (PDF) is available. Learn about new and revised files available starting September 13.

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – October 2019 Update — Revised

A revised MLN Matters Article MM11422 on Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – October 2019 Update (PDF) is available. Learn about 44 new HCPCS codes.

Publications

Quality Payment Program: Resources for Clinicians New to the Program in 2019

New clinician types became eligible to participate in the Quality Payment Program this year, including clinical psychologists, physical therapists, occupational therapists, qualified speech-language pathologists, qualified audiologists, and registered dieticians and nutrition professionals CMS posted resources on the Resource Library webpage to help you understand how to successfully participate in the Merit-based Incentive Payment System (MIPS) in 2019:

Participation and Eligibility Fact Sheet - Opens in a new window : Overview of the eligibility criteria
Participating in QPP Infographic - Opens in a new window : How to check your participation status, basic requirements for participation, and key dates
MIPS Eligibility Decision Tree - Opens in a new window : A series of questions to help you determine if you are eligible
Quick Start Guide: Eligibility requirements, low-volume threshold criteria, exclusions, and timeline
Specialty Measures Guides for clinical psychologists - Opens in a new window , physical therapists and occupational therapists - Opens in a new window , speech-language pathologists and audiologists - Opens in a new window , and registered dietitian and nutrition professionals - Opens in a new window : A sample of performance year measures and activities

For More Information:

Quality Payment Program website
Contact the Quality Payment Program at 866-288-8292 (TTY: 877-715-6222) or

Medicare Enrollment for Physicians and Other Part B Suppliers — Reminder

A Medicare Learning Network Booklet is available. Learn:

Who are part B suppliers
What it means to be a participating provider

Medicare Preventive Services Poster — Reminder

A Medicare Learning Network Educational Tool is available. Learn about:

Coding
Coverage requirements
Patient cost-sharing for each service

Safeguard Your Identity and Privacy Using PECOS — Reminder

The Medicare Learning Network Booklet is available. Learn:

How to use the Provider Enrollment, Chain, and Ownership System (PECOS)
Privacy tips
How to keep, review, and protect enrollment information

Multimedia