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CMS Update

CMS Update. Rural Health Association of Oklahoma September 23, 2010. What’s New?. Dr. Donald Berwick named as CMS Administrator on July 7, 2010 Former President and CEO of the Institute for Healthcare Improvement Clinical Professor of Pediatrics and Health Care Policy at Harvard Medical School.

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CMS Update

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  1. CMS Update Rural Health Association of OklahomaSeptember 23, 2010

  2. What’s New? • Dr. Donald Berwick named as CMS Administrator on July 7, 2010Former President and CEO of the Institute for Healthcare ImprovementClinical Professor of Pediatrics and Health Care Policy at Harvard Medical School

  3. RHC Regulation – Soon? • Balanced Budget Act of 1997 enacted • February 2000 – First Proposed Rule • December 2003 – Final Rule issued, but suspended due to new statutory requirement (MMA of 2003) that no more than 3 years can elapse between a proposed and final rule • June 2008 – New Proposed Rule issued • MMA 2003 requires Final Reg to be published within 3 years of Proposed Rule = June 2011

  4. Patient Protection and Affordable Care Act (PPACA) Enacted 3/23/10 • Preventive Services Changes Beginning 1/1/2011:Coverage of Annual Wellness Visit Providing a Personalized Prevention Plan (initial and subsequent visits) • Elimination of Beneficiary Cost-Sharing for Preventive Services for Annual Wellness Visit, Initial Preventive Physical Exam (IPPE), and other Medicare preventive services recommended by USPSTF with a grade of A or B

  5. Coinsurance and Deductible Waived Beginning in 2011 • Annual Wellness Exam, IPPE, Abdominal Aortic Aneurysm Ultrasound Screening, screening lab tests for diabetes and cardiovascular disease, PAP test, screening pelvic exam, screening mammography, bone mass measurement, PSA test, colorectal cancer screenings (except barium enema), HIV screening lab tests, vaccine and administration for flu, pneumococcal and hepatitis B, medical nutrition therapy

  6. Preventive Cost Sharing Still Applies • Diabetes Self-Management Training (DSMT) – coinsurance and deductible apply • Barium Enema as colorectal cancer screening – coinsurance applies, deductible is waived • Digital rectal exam as prostate cancer screening – coinsurance and deductible apply • Glaucoma screening for high risk patients – coinsurance and deductible apply

  7. PPACA Primary Care Incentive • 1/1/11 - 10% bonus for primary care physicians, NPs, CNSs, PAs for whom primary care services = at least 60% of allowed Part B charges in a prior period (first time will use CY 2009 PFS claims data processed through 6/30/10), paid quarterly for primary care services furnished during that quarterPaid in addition to usual 10% HPSA bonus

  8. PPACA Surgical Incentive • 1/1/11: 10% bonus to general surgeons when furnishing a major surgery (10 or 90 day global) in a geographic HPSA, paid quarterly • Paid in addition to usual HPSA bonus payment

  9. Patient Protection and Affordable Care Act (PPACA) • Changes timely filing deadline to one year, beginning with services provided on or after 1/1/10, Services provided from 10/1/09 to 12/31/09 must be filed by 12/31/10. At this point, there are no exceptions to the new requirement. • Watch Medicare contractor listserv for earliest news on other changes as they become known

  10. 2011 Physician Fee Schedule Regulation – Proposed 7/13/10 • Propose to add to telehealth benefit: • Individual and group kidney disease education services (G0420-1) • Individual and group DSMT services (G0108-9) • Group MNT and Health and Behavior Intervention services (97804, 96153-4) • Subsequent hospital care services (99231-3) • Subsequent SNF/NF services (99307-10)

  11. 2011 PFS Proposed Rule • Affordable Care Act (PPACA) requires PPS system be developed for FQHCs by 2014 • PFS proposes to begin collecting data to develop new PPS on 1/1/2011 • 1/1/2011 FQHCs will be required to file claims using HCPCS codes (not currently required)

  12. 2011 PFS Proposed Rule • ACA reinstates physician work geographic floor, protection of frontier states, payment of technical component of physician pathology services, ambulance add-on, reasonable cost for lab in rural hospitals <50 beds • ACA changes payment for certified nurse midwife services to the same as physicians on Medicare fee schedule (80% of allowable charge)

  13. Inpatient Prospective Payment System Final Rule Effective 10/1/2010 • Acute care transfer policy will now apply to patients discharged to critical access hospitals and non-participating hospitals (not VA or DoD) • Payment adjustments for low volume hospitals in 2011-12 if hospital is more than 15 mi. from another subsection (d) hospital and has fewer than 1,600 discharges for patients entitled to Part A in the fiscal year

  14. IPPS Final Rule • Medicare Dependent Hospital – extended through FY 2012 (ending 10/1/12) and will count all days/discharges of patients entitled to Medicare Part A beginning 10/1/10 • CRNA Services furnished in rural hospitals and CAHs – for cost reporting periods beginning on or after 10/1/10, CAHs and hospitals reclassified according to 1886(d)(8)(E) and Sec. 412.103 are also rural and can be paid reasonable cost for CRNA services (Lugar N/A)

  15. IPPS Final Rule • $400 million in Payments for Qualifying Hospitals with Lowest Per Enrollee Medicare Spending – subsection (d) hospital located in an eligible county, paid in FY 2011 and FY 2012 • Rural Community Hospital Demo extended to 20 states with low population density and to 20 more hospitals

  16. IPPS Final Rule • PPACA changes 3-day payment window implementation for non-CAH hospitals – hospitals must include on inpatient bill the diagnoses, procedures, and charges for all outpatient preadmission diagnostic services and all outpatient preadmission nondiagnostic services (except ambulance and maintenance renal dialysis) provided by the subsection (d) hospital or entity that is wholly owned or operated by the hospital

  17. IPPS Final Rule • Services on date of admission are deemed related and also services provided on the first, second and third calendar day prior to the admission are also deemed related to the admission unless the hospital attests that the services are not related to the admission • A “Related” outpatient service is one that is clinically associated with the reason for a patient’s inpatient admission

  18. IPPS Final Rule • CAHs electing Method 2 no longer required to make annual re-election, unless wish to terminate election 30 days before cost report period end • If CAH CR period begins in October 2010 or November 2010 and elected Method 2 in 2009 and wish to terminate Method 2, you have until 12/1/2010 to do so

  19. IPPS Final Rule • PPACA made conforming change for CAHs to make 101% of reasonable cost for Method 2 and to make 101% of reasonable cost for CAH-based ambulances, retro to 1/1/2004, but no reprocessing since contractors paid the claims this way anyway • CAHs can claim provider taxes as allowable costs only to the extent the assessed taxes are actually incurred

  20. Outpatient Prospective Payment System Proposed Rule 8/3/10 • Hold Harmless Transitional Payments expires on 1/1/2011 • Physician Supervision Policy for Outpatient diagnostic services: hospitals (but not CAHs) must follow MPFS physician supervision requirements for individual tests (general, personal, or direct) for services provided directly or under arrangement for services provided onsite in hospital, provider-based department or nonhospital location

  21. OPPS Proposed Rule • For outpatient therapeutic services in hospitals and CAHs, proposing changes and requesting comments: for a limited set of services with a significant monitoring component that are not surgical and typically have a low risk of complication, would require direct physician supervision for the initiation of the service followed by general supervision for the remainder of the service (list does not include chemo and blood transfusions)

  22. OPPS Proposed Rule • Proposing to revise the MPFS to apply a multiple procedure reduction to payment for all outpatient physical and occupational therapy services • Proposing changes to whole hospital and rural provider exceptions to the physician self-referral prohibition

  23. Ordering/Referring Update • CMS is delaying implementation of CR 6417 and CR 6421 until January 3, 2011 to give all physicians and practitioners time to update their enrollment information in PECOS. Applies to physicians, PA, NP, CNM, CNS, CP and CSW.Once implemented, Part B CMS 1500 claims for services that were ordered/referred will need to include ordering/referring NPI information. If the ordering/referring physician is not in PECOS, the claim will be rejected and later denied.

  24. Regulation Implementing PPACA • 5/5/10 Interim Final Regulation implements provision of law to permit only a Medicare enrolled physician/eligible professional to certify or order home health, DMEPOS supplies and other Part B services, and applies to orders, referrals and certifications on and after 7/1/10, comment period closes 7/6/10. • CMS will not implement automatic rejection of claims for services ordered by providers whose PECOS applications have not been approved by 7/6/10 – (CMS Press Release 6/30/10)

  25. Ordering/Referring PECOS File • www.cms.hhs.gov/MedicareProviderSupEnroll • Over 800,000 names and NPIs on file in PECOSof physicians and non-physician practitioners eligible to order/refer • Sorted in alpha order by last name, with NPI

  26. Ordering/Referring for RHC/FQHC/CAH Physicians • Physicians/NPPs who would not be sending claims to Medicare Part B can still enroll for the sole purpose of ordering or referring • Paper form CMS-855I, complete only certain sections, and attach a cover letter stating provider is only enrolling to order and refer services for a beneficiary and cannot be reimbursed for services performed • Mail application to designated Part B MAC provider enrollment address (see TrailBlazer website www.trailblazerhealth.com for details)

  27. Internet-Based PECOS Enrollment • Available to Part B individuals, groups, organizations and Part A providers • https://pecos.cms.hhs.gov • RHCs, FQHCs not allowed to use the Internet-based PECOS • All providers use paper 855 for filing changes of ownership, acquisition, mergers, consolidations, changes in tax ID, changes in legal business name

  28. Rejection of Enrollment Application • CMS contractors may reject a provider’s or supplier’s enrollment application if they fail to furnish complete information on the application within 30 calendar days from the date of the contractor’s request for the missing information • After rejection, a provider or supplier must complete and submit a new enrollment application and documentation for review and approval

  29. Recent Enrollment Changes • Establishes an effective date of billing for physicians, non-physician practitioners and physician and NPP organizations as the later of1) the filing of an enrollment application that is subsequently approved or 2) the date an enrolled physician or NPP first started furnishing services at a new practice location

  30. Recent Enrollment Changes • Permits physicians and non-physician practitioners to retrospectively bill for services rendered up to 30 days prior to the effective date, if they met all program requirements or services rendered up to90 days prior when there is a Presidentially-declared disaster • No longer unlimited retroactive billing

  31. Recent Enrollment Changes • Requires all providers and suppliers, including individual practitioners, to maintain ordering and referring documentation for 7 years from the date of service

  32. Enrollment Reportable Events – 30 Day Timeframe • All providers/suppliers must report a change in ownership or control on CMS 855 form within 30 days • Physicians and non-physician practitioners are required to report the following changes on CMS 855 form within 30 days of these events: • 1. Change of ownership • 2. Change in practice location • 3. Final adverse action

  33. Penalties for Not Meeting 30-Day Reportable Events • Failure to notify the Medicare contractor of these changes may result in a revocation (termination of billing privileges) and/or overpayment from the date of the reportable change • Providers/suppliers whose billing privileges are revoked may be barred from re-enrolling in Medicare for 1-3 years

  34. Enrollment Reportable Events – 90 Day Timeframe • Physician and non-physician practitioners are required to report on CMS 855 form the following changes no later than 90 days after the event: • 1) Change in practice status (e.g., retirement) • 2) Change of business structure, legal business name or taxpayer ID Number • 3) Change of banking arrangements or payment information • 4) A change in the correspondence or special payments address

  35. Enrollment Reportable Events – 90 Day Timeframe • All providers/suppliers must report on CMS 855 form within 90 calendar days of the following changes: • Change in practice location • Change of any managing employee • Change in billing services • Other changes

  36. Penalties for Not Meeting 90-Day Reportable Events • Medicare contractors may deactivate a provider or supplier’s Medicare billing privileges for failure to report changes within 90 days of the event, and providers/suppliers must complete and submit a new enrollment application to reactivate Medicare billing privileges

  37. Periodic Revalidation of Medicare Enrollment Information • Providers/suppliers (other than DMEPOS and ambulance) must resubmit and recertify the accuracy of its enrollment information every 5 years • CMS Medicare contractors will contact providers and suppliers directly when it is time to revalidate their information • Providers/suppliers must submit complete application and documentation within 60 calendar days of the notification

  38. Penalty for Failure to Respond to Revalidation Request • Providers who fail to respond to the CMS Medicare contractor’s revalidation request may have billing privileges revoked and may be barred from re-enrolling in Medicare for one year

  39. More Information on Medicare Enrollment • Go to CMS website www.cms.gov/MedicareProviderSupEnroll • CMS Internet Only Manual 100-08, Chapter 10 • Federal Regulations 42 CFR 424.500

  40. A/B MAC Implementation • MMA 2003 requires geographic assignment of providers • All new Part A or Part B providers enroll with the Medicare Administrative Contractor (MAC) serving their state, or with the legacy contractor serving the state if there is no MAC yet • New freestanding RHCs and FQHCs (including FQHC satellites) are no longer assigned to regional or national FIs (only HHA/hospice and DMEPOS are still assigned to regional MACs) • New Freestanding RHCs now enroll with the MAC for their state, or if the MAC has not been awarded yet, it will enroll with the local Medicare fiscal intermediary in their state • New Provider-Based RHCs and other provider-based entities continue to enroll with the FI/MAC that serves the parent provider

  41. A/B MAC Implementation • Existing Out-of-jurisdiction providers (e.g., those with Mutual/WPS, and providers with former regional or national FIs that are not the MACs for the state where they are located) will not transition to the MAC for their state until after all the MAC contracts are fully implemented • WPS/Mutual providers in J4 jurisdiction are in the process of being transitioned to J4 by October 18, 2010

  42. Medicare Advantage Payment Guide • CMS guidance to MA plans regarding original Medicare payments to providers (for PFFS plan payments and out-of-network provider payments): http://www.cms.hhs.gov/MedicareAdvtgSpecRateStats/downloads/oon-payments.pdf

  43. Be Prepared – New X12 Standards • HIPAA Version 5010 Level I Compliance by 12/31/10 (covered entities demonstrate they can create and receive compliant transactions) and Level II Compliance by 1/1/12 (covered entities complete testing with all trading partners and are able to operate in production mode with new version of the standards) • http://www.cms.hhs.gov/Versions5010andD0 (note the last is a zero)

  44. Be Prepared – ICD-10 • 1/16/09 HIPAA Final Rule to adopt ICD-10-CM and ICD-10-PCS by October 1, 2013 for all covered entities • http://www.cms.hhs.gov/ICD10 for info on educational resources, code tables and descriptions, mappings, etc.

  45. PS&R Reports via Internet • Must establish an IACS account and be approved for PS&R access • IACS verification process includes the submission of supporting documentation and may take several weeks to complete the entire process, so start in advance of when you need it for cost report preparation • CMS PS&R Redesign Web page has user manuals, guides, etc. (link on TrailBlazer website, and CMS website CR 6519)

  46. CMS/HHS Rural Resources • CMS Open Door Forum Calls:http://www.cms.hhs.gov/OpenDoorForums for information on signing up for Rural Open Door listserv • CMS Web site Rural Health Clinic Centerhttp://www.cms.hhs.gov/center/rural.asp • HRSA Office of Rural Health Policy Rural Assistance Center – one-stop shopping for all Department of HHS rural infohttp://raconline.org

  47. CMS Rural Resources • Medicare Learning Network: http://www.cms.hhs.gov/MLNGenInfo • Medlearn Matters Listserv:https://list.nih.gov • Sign up for your Medicare contractor’s listserv:http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip to get web address of your contractor’s homepage

  48. Medicare & Medicaid EHR Incentive Program

  49. A Short History of MU • American Recovery & Reinvestment Act (Recovery Act) – February 2009 • Medicare & Medicaid Electronic Health Record (EHR) Incentive Program Notice of Proposed Rulemaking (NPRM) • Publication – January 13, 2010 • NPRM Comment Period Closed – March 15, 2010 • CMS received 2,000+ comments • Final Rule on Display – July 13, 2010 • Final Rule Published – July 28, 2010

  50. Three-Legged Stool Meaningful Use • Final Rule released by CMS in July, 2010 Standards • Final Rule released by ONC in July, 2010 Certification • Temporary Program Final Rule released by ONC in June, 2010 Meaningful Use Certification Standards

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