Medicare Compliance & Reimbursement

If you were beginning to think that CMS had a specialty code for almost everything, here's news that will bolster your suspicions. The agency recently announced that it would be issuing new specialty code 'C1' to designate non-physician practitioners whose primary specialty is centralized flu.

Although CMS does not expound on how to use the specialty code, most analysts believe that it will be used by facilities that perform mass flu immunizations. The new code will not be billable until midway through the upcoming flu season, since it takes effect on Jan. 1, 2013.

Specialty code C1 is only applicable to the CMS-855B enrollment application, CMS notes in MLN Matters article MM7884. To read more about the new code, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7884.pdf.

Will CMS Implement Pre-Pay Audits in Your State?

Prepare yourself: Starting August 27, 2012 CMS began its Recovery Audit Prepayment Review prepayment audits in 11 states, according to an announcement on the agency's Web site.

This program ... will allow Medicare Recovery Auditors (RACs) to review claims before they are paid to ensure that the provider complied with all Medicare payment rules, according to CMS. The RACs will conduct prepayment reviews on certain types of claims that historically result in high rates of improper payments. These reviews will focus on seven states with high populations of fraud- and error-prone providers (FL, CA, MI, TX, NY, LA, IL) and four states with high claims volumes of short inpatient hospital stays (PA, OH, NC, MO) for a total of 11 states. This demonstration will also help lower the error rate by preventing improper payments rather than the traditional 'pay and chase' methods of looking for improper payments after they occur. This demonstration will begin on August 27, 2012.

Originally, the Recovery Audit Prepayment Review demonstration projection, announced in November 2011, was slated to start on Jan. 1. CMS then delayed it until June 1, and then again to a vague implementation date of summer of 2012.

To read more about the reviews, visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/Demonstrations.html

Get Ready: CMS Plans to Move Medicare SNF payments from Volume to Value-based

In June, CMS sent a report to Congress detailing its plans to implement a Value-Based Purchasing Program (VBP) for skilled nursing facilities. We see the future of health care reimbursement moving from the current volume-based payment methodology to value-based purchasing, David Gifford, MD, MPH, senior vice-president quality and regulatory affairs, for the American Health Care Association (AHCA), tells Eli. Both AHCA and the National Center for Assisted Living (NCAL) strongly support this move, he notes.

The report, which was required by Section 3006 of the Affordable Care Act, discusses the current state of various elements that would be part of a SNF VBP and where the agency will go from there, explains Cassandra Black, senior technical advisor for CMS's Performance-Based Payment Policy Group. These include the following:

• The agency's current quality measures and process for developing them;
• Additional quality measures that the agency may want to add;
• A description of the process for reporting the measures;
• How payments could potentially be structured;
• Types of incentive payments;
• Possible funding sources for the payments; and
• How the agency would share any information gathered with the public.

The report concludes with a roadmap for implementation of a SNF VBP. CMS will analyze the results of the recently concluded Nursing Home Value Based Purchasing demonstration project, expected to be ready in the fall of 2013, before moving forward with a SNF VBP, Black notes.

Gifford says that this report summarizes many of the ongoing demonstrations on VBP which is helpful guide as SNFs transition from fee-for-service to value based purchasing. Copies of the report are available at: www.cms.gov/snfpps.

New Round Of DME Bidding Launched

Registration is now open for Medicare's competitive bidding round 1 re-compete for durable medical equipment, CMS has announced. The registration period will end Oct. 19, though CMS had urged DME suppliers to register their authorized official in the Individuals Authorized Access to the CMS Computer Services (IACS) system by Sept. 7.

Six categories of items are included in the round 1 re-compete, bidding contractor Palmetto GBA says on the bidding site online at www.dmecompetitivebid.com. They include Respiratory Equipment and Related Supplies and Accessories (oxygen, oxygen equipment, and supplies; continuous positive airway pressure [CPAP] devices and respiratory assist devices [RADs] and related supplies and accessories; and standard nebulizers); Standard Mobility Equipment and Related Accessories (walkers, standard power and manual wheelchairs, scooters, and related accessories); General Home Equipment and Related Supplies and Accessories (hospital beds and related accessories, group 1 and 2 support surfaces, transcutaneous electrical nerve stimulation [TENS] devices, commode chairs, patient lifts, and seat lifts); Enteral Nutrients, Equipment and Supplies; Negative Pressure Wound Therapy Pumps and Related Supplies and Accessories; and External Infusion Pumps and Supplies.

Court Case Spotlights How Hospice Patients Can Appeal Denials

Hospices may have to cover more drugs and services they don't approve, thanks to a court case clarifying how hospice beneficiaries can appeal hospices' coverage decisions.

In an opinion released last month, the U.S. Court of Appeals for the Ninth Circuit informed the plaintiff that Medicare has an official appeals process for hospice beneficiaries who want to dispute drugs or services a hospice doesn't cover.

Background: In 2007, Howard Back's wife was prescribed Actiq for uncontrolled pain, but the hospice didn't cover it, according to the opinion in Back v. Sebelius. Back paid nearly $6,000 for the drug out of pocket until his wife died in March 2008. When Back submitted the bill to the hospice, it declined to pay. Then Back received a series of incorrect information from the hospice, the contractor, and CMS about how to appeal. Back ultimately filed suit and was told in the district court that there really was an appeals process for the issue with CMS and Back had to use it before filing suit. Upon appeal, the circuit court dismissed the suit for the same reason.

We understand Back's frustration, having been misinformed by CMS and forced to hire an attorney and bring suit to be properly informed of his right to appeal, the opinion says. However, Back already has the only relief he seeks -- he and other hospice beneficiaries may utilize the [HHS] Secretary's procedures to appeal a hospice provider's refusal to provide a drug or service. We expect that the Secretary will take action to ensure that her agencies are properly informed in the future.

Expect an increasing emphasis on education surrounding beneficiary appeal rights under Medicare as a result of this case, says the National Association for Home Care & Hospice. The opinion is at www.ca9.uscourts.gov/datastore/opinions/2012/07/05/11-55175.pdf.

Avoid These Diagnoses On Your Hospice Claims To Quell Denials

Don't submit a hospice claim with one of these diagnoses, unless your documentation thoroughly backs it up -- Debility, Alzheimer's disease, and Chronic Airway Obstructions. Medicare Administrative Contractor CGS is continuing a widespread review of hospice claims with these diagnoses, it says on its website.

In a probe review that ran from October 2011 through March 2012, CGS denied most claims for failing to show the terminal prognosis or for certifications that were missing, incomplete or not timely, the MAC says. Hospices also failed to submit documentation at all in response to the ADR.

Reminder: The patient's appropriateness for the hospice benefit must be clearly supported in the medical record from admission and throughout the hospice care provided, CGS tells hospices. Look to local coverage decisions for tips on improving documentation of the terminal prognosis, the MAC adds.