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MLN Connects for December 5, 2019
MLN Connects newsletter, official Centers for Medicare & Medicaid Services (CMS) news from the Medicare Learning Network

Thursday, December 5, 2019



Claims, Pricers & Codes


MLN Matters® Articles



View this edition as a PDF (PDF)




Direct Contracting Risk-Sharing Options: Submit Letter of Intent by December 10

Direct Contracting creates a variety of pathways for health care providers and suppliers to take on financial risk supported by enhanced flexibilities. Because the model reduces burden, supports a focus on complex, chronically and seriously ill patients, and aims to encourage organizations to participate that have not typically participated in Medicare fee-for-service, Innovation Center models, or both, CMS anticipates that this model will appeal to a broad range of physician and other types of health organizations. 

We will test two voluntary risk-sharing options:

  • Professional: Lower-risk option (50% shared savings/shared losses) and primary care capitation equal to 7% of the total cost of care benchmark for enhanced primary care services
  • Global: Full risk option (100% shared savings/shared losses) and either primary care capitation or total care capitation

The Letter of Intent (LOI) is open until December 10 for those organizations that did not submit an LOI previously. Visit the Direct Contracting Model Options webpage for more information.

See the full text of this excerpted CMS Fact Sheet (issued November 25).


DMEPOS Competitive Bidding Surveys: Comment by December 20

CMS is soliciting comments on:

  • Questions to ask in surveys of key stakeholders (e.g., beneficiaries, contract suppliers, and referral agents) to help us further strengthen the monitoring, outreach, and enforcement of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program
  • Effective methods for contacting referral agents, as they play a critical role in helping beneficiaries obtain competitively bid DMEPOS items

We will accept comments through December 20. For more information, see the Public Comments on Competitive Bidding Surveys webpage.


Quality Payment Program: Technical Expert Panel Nominations due December 20

CMS is seeking nominations to a Technical Expert Panel (TEP) that will provide guidance for activities under the Physician Cost Measures and Patient Relationship Codes contract. Nominations are due December 20. Visit the TEP webpage for more information.


Quality Payment Program: MIPS Exception Applications due December 31

If you are interested in applying for a Promoting Interoperability Hardship Exception or Extreme and Uncontrollable Circumstances Exception for the 2019 Performance Year of the Merit-based Incentive Payment System (MIPS), you must submit your application by December 31.

For More Information:


Clinical Laboratory Fee Schedule: CY 2020 Final Payment Determinations

The Clinical Laboratory Fee Schedule (CLFS) CY 2020 Final Test Codes Payment Determinations (ZIP) are available. For more information on the payment determination process, visit the CLFS Annual Public Meeting website.


Quality Payment Program: 2019 APM Incentive Payment Details

The Quality Payment Program website is updated to include 2019 Alternative Payment Model (APM) incentive payment details. See the fact sheet for more information.


PEPPERs for Short-term Acute Care Hospitals

Third quarter FY 2019 Program for Evaluating Payment Patterns Electronic Reports (PEPPERs) are available for short-term acute care hospitals. These reports summarize provider-specific statistics for Medicare services that may be at risk for improper payments. You can use the data to support internal auditing and monitoring activities. The PEPPER files were recently distributed through a QualityNet secure file exchange to hospital QualityNet Administrators and user accounts with the PEPPER recipient role.

For More Information:


eCQM Reporting: Updated 2020 QRDA III Implementation Guide

CMS released an update to the 2020 Quality Reporting Document Architecture (QRDA) Category III Implementation Guide for eligible clinicians and eligible professionals along with the Schematron and Comprehensive Primary Care (CPC+) Sample File to support electronic Clinical Quality Measure (eCQM) reporting. This update includes changes from the Physician Fee Schedule Final Rule.

The Implementation Guide outlines requirements for eligible clinicians and eligible professionals to report eCQMs, Improvement Activities, and Promoting Interoperability measures for the CY 2020 performance period for these programs:

  • Quality Payment Program: Merit-based Incentive Payment System and Advanced Alternative Payment Models
  • CPC+
  • Medicaid Promoting Interoperability Program

For More Information:


National Influenza Vaccination Week

National Influenza Vaccination Week is a national observance that highlights the importance of continuing influenza vaccination efforts through the holiday season and beyond. The Centers for Disease Control and Prevention (CDC) recommends annual influenza vaccination for everyone 6 months and older. It’s not too late to vaccinate – to help protect your patients, your staff, and yourself.

Medicare Part B covers:

  • Influenza virus vaccine once per influenza season
  • Additional influenza vaccines if medically necessary

For More Information:


National Handwashing Awareness Week

Practicing hand hygiene is a simple and effective way to prevent infections. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics. Create a safe environment for your patients and staff.

Medicare Learning Network resources:

  • Infection Control: Hand Hygiene Video: Learn when to wash your hands and techniques to wash visibly and non-visibly dirty hands — run time 1:58
  • Infection Control: Hand Hygiene Web-Based Training Course: Learn about hand hygiene in patient care zones and nearby administrative areas; appropriate methods for maintaining good hand hygiene; and how to recognize opportunities for hand hygiene in a health care setting — with continuing education credit




Cardiac Device Credits: Medicare Billing

A 2018 Office of the Inspector General (OIG) Report noted that payments reviewed for recalled cardiac medical devices did not comply with Medicare requirements for reporting manufacturer credits. Medicare incorrectly paid hospitals $7.7 million for cardiac device replacement claims, resulting in potential overpayments of $4.4 million. Manufacturers issued reportable credits to hospitals for recalled cardiac medical devices, but the hospitals did not adjust the claims with the proper condition codes, value codes, or modifiers to reduce payment as required.

CMS developed the Medicare Billing for Cardiac Device Credits (PDF) Fact Sheet to ensure that hospitals properly report manufacturer credits for cardiac devices and avoid overpayment recoveries. Additional resources:


Claims, Pricers & Codes


Average Sales Price Files: January 2020

CMS posted the January 2020 Average Sales Price (ASP) and Not Otherwise Classified (NOC) pricing files and crosswalks on the 2020 ASP Drug Pricing Files webpage.


Home Health RAPs: Hold Starting January 1, 2020

Medicare Administrative Contractors (MACs) typically hold claims for a brief period each quarter when they implement system releases. This January, home health Requests for Anticipated Payment (RAPs) are affected by implementation of the Home Health Patient-Driven Groupings Model. MACs will hold RAPs with From Dates on or after January 1, 2020, and process them once the updates are complete.




Hospital Price Transparency Special Open Door Forum — December 10

Tuesday, December 10 from 2 to 3 pm ET

This Special Open Door Forum allows stakeholders to ask questions about the recently released price transparency rules:

See the announcement (PDF) for more information.


Medicare Promoting Interoperability Program 2020 Webinar — January 16

Thursday, January 16 from 1 to 2 pm ET

Register for this webinar.

During this webinar, CMS reviews major changes to the Medicare Promoting Interoperability Program for 2020, including:

  • 2020 electronic health record reporting period
  • 2015 edition CEHRT requirements
  • Objective/measure changes
  • Scoring

Attendees will also have the opportunity to ask questions during a Q&A session following the presentation.


MLN Matters® Articles


Overview of the Patient-Driven Groupings Model

A new MLN Matters Article SE19027 on is available. Learn about implementation of the new Patient-Driven Groupings Model for home health periods of care starting on and after January 1, 2020.


Payments and Payment Adjustments under the Patient-Driven Groupings Model

A new MLN Matters Article SE19028 on Payments and Payment Adjustments under the Patient-Driven Groupings Model (PDF) is available. Learn about changes for home health periods of care starting on and after January 1, 2020.


Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for Calendar Year (CY) 2020 - Recurring File Update

A new MLN Matters Article MM11500 on Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for Calendar Year (CY) 2020 - Recurring File Update (PDF) is available. Learn about updates to the base payment rate and the geographic adjustment factors.




Disproportionate Share Hospital — Revised

A revised Disproportionate Share Hospital Medicare Learning Network Fact Sheet is available. Learn about:

  • How to quality for an adjustment
  • Counting number of beds and patient days
  • Adjustment formulas


Federally Qualified Health Center — Revised

A revised Federally Qualified Health Center Medicare Learning Network Booklet is available. Learn about:

  • How to certify
  • Patient services and visits
  • Payment
  • Cost reports


Medicare Learning Network (MLN) Learning Management System (LMS) FAQs — Revised

A revised Medicare Learning Network (MLN) Learning Management System (LMS) FAQs Booklet is available. Learn how to:

  • Access the LMS
  • Find products
  • Take web-based training
  • Print your certificate




Clinical Labs Call: Audio Recording and Transcript

An audio recording (ZIP) and transcript (PDF) are available for the November 14 Medicare Learning Network call on the Clinical Diagnostic Laboratory Test Payment System: Data Reporting. Learn how to register in the system and submit then certify data.


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