CMS Updates. CMS Releases FY 2015 Proposed IPPS. Protecting Access to Medicare Act of 2014 (H.R. 4302)

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CMS, Medicare Administrative Contractor,

and Recovery Auditor Activity Updates

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CMS Updates

CMS Releases FY 2015 Proposed IPPS

On May 1, 2014, CMS released the FY 2015 Inpatient Prospective Payment System (IPPS) proposed rule. In the proposed rule, CMS is seeking public comment on an alternative payment methodology for short inpatient hospital stays. CMS is also continuing to seek suggestions of other services and procedures (other than Inpatient-Only and Mechanical

Ventilation) that would justify inpatient admission and Part A payment absent an expectation of care spanning at least 2 midnights. In the proposed rule, CMS is proposing to amend the regulations governing the timing of the 96-hour certification requirement at § 424.15(b) such that physician certification is required no later than 1 day before the date on which the claim for payment for the inpatient CAH service is submitted and not prior to discharge. Similarly, CMS is proposing to amend 424.11(d)(5) to allow CAHs to perform a delayed certification after discharge. CMS seeks public comment on these proposed changes.

Comments are due no later than 5:00 PM on June 30, 2014.

Protecting Access to Medicare Act of 2014 (H.R. 4302)

The Protecting Access to Medicare Act of 2014 was passed by the Senate on March 31, 2014 and signed into law by President Obama on April 1, 2014. The passage of H.R. 4302 marked the 17th time since 2003 that Congress has acted to temporarily delay cuts to doctor reimbursements under Medicare. This act defers until April 1, 2015 the SGR

(sustainable growth rate) mandated 24% reimbursement cut required by the Balanced Budget Act of 1997 for physicians treating Medicare patients. This law also delays national implementation of ICD-10 and CMS has yet to provide clarity for how hospitals, doctors, and insurance companies should move forward.

Section 111(a) of the Protecting Access to Medicare Act of 2014 allows for the Secretary of Health and Human Services to discretionarily extend the Probe and Educate program for an additional 6 months (it is currently slated to run through October 31, 2014).

Section 111(a) states that Recovery Audit contractors shall not conduct patient status reviews (0-1 day stays as described in the “Selecting Hospital Claims for Patient Status Reviews” notice) on a post-payment review basis for inpatient claims with dates of admission October 1, 2013, through March 31, 2015, unless there is evidence of systematic gaming, fraud, abuse, or delays in the provision of care by a provider of services.

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Medicare Administrative Contractor by State

Cahaba

CGS

FCSO

NGS

NORIDIAN

NOVITAS

PALMETTO WPS

J10

JI

J9

J6

JF

JH

J11

J5

Alabama

Kentucky Florida Minnesota

Alaska

New Mexico North

Carolina

Iowa

Georgia

Ohio

US

Virgin

Islands

Wisconsin

Arizona

Colorado

South

Carolina

Kansas

Tennessee

Puerto

Rico

Illinois

Idaho

Texas

Virginia

Missouri

JK

Montana

Oklahoma

West

Virginia

Nebraska

New York

North

Dakota

Arkansas

J8

Connecticut

Oregon

Louisiana

Michigan

Maine

South

Dakota

Mississippi

Indiana

Rhode Island

Utah

JL

Vermont

Washington Pennsylvania

New

Hampshire

Wyoming

Maryland

Massachusetts JE

New Jersey

California

Delaware

Hawaii

Nevada

American

Samoa

Guam

Northern

Mariana

Islands

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Medicare Administrative Contractor Updates

Cahaba Government Benefit Administrators

**Cahaba GBA’s Current Prepayment Medical Review Log for Part A*:**

 Inpatient Rehabilitation Facility A0801-A0806 and A0701-A0703  Inpatient Rehab A2001-A2004

 Condition Code 07-The patient has elected hospice care but the provider is not treating the terminal condition, and is, therefore, requesting regular Medicare payment.

 Final Rule CMS 1599-F, 2 Midnight Rule Inpatient Admissions

*Cahaba GBA last updated this list on April 3, 2014. This is not an exhaustive list; the complete list can be found at

http://www.cahabagba.com/part-a/medical-review/j10-ab-mac-prepayment-medical-review-log-part-a/.

Cahaba GBA website: https://www.cahabagba.com/part-a/

CGS

No new contractor specific information at this time.

CGS Website: http://www.cgsmedicare.com/parta/index.html#

First Coast Service Options

On February 14, 2014, the Centers for Medicare & Medicaid Services (CMS) selected First Coast Service Options Inc. (First Coast) to continue to be the Medicare administrative contractor (MAC) for Florida, Puerto Rico and U.S. Virgin Islands. As a result of the transition to the new contract, effective June 16, 2014, jurisdiction 9 (J9) will be referred to as jurisdiction (JN).

For the full article about FCSO’s contract award, follow this link: FCSO Contract Award

Note: As of October 1, 2013, FCSO has removed every DRG from prepayment review.

The complete details of FCSO inpatient DRGs subject to prepayment medical review, including the CERT and FCSO error rate findings for each issue, can be found at: http://medicare.fcso.com/wrapped/231916.asp

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National Government Services

National Government Services website: http://www.ngsmedicare.com/wps/portal/ngsmedicare/home

Noridian Healthcare Solutions

These service-specific prepayment reviews are currently in effect in Noridian Jurisdiction F:  DRG 287 - Circulatory disorders except AMI, w card cath w/o MCC (Targeted Review)

o States Affected: WA, AK, ID, OR

These service-specific prepayment reviews are currently in effect in Noridian Jurisdiction E:

 DRG 460 - Spinal Fusion except Cervical without Major Complications or Comorbidities (MCC) o States Affected: CA, NV

These service-specific prepayment reviews are state specific. The list of affected states, along with interim findings can be found at https://www.noridianmedicare.com/parta/coverage/service_specific_review.html#ipps (JF) and

https://med.noridianmedicare.com/web/jea/cert-reviews/mr/notifications-findings (JE)

Noridian Healthcare Solutions: https://www.noridianmedicare.com/parta/ (JF) and

https://med.noridianmedicare.com/web/jea (JE)

Novitas Solutions, Inc.

Novitas Service Wide (Widespread) Edits (Jurisdiction H):

PLEASE NOTE: THE FOLLOWING EDITS HAVE ALL BEEN SUSPENDED

 DRG 227: Cardiac Defibrillator Implant without cardiac cath without Major Complication/Co morbidity (MCC) with length of stay < 3 days

 DRG 243: Permanent Cardiac Pacemaker Implant with CC (Complications/Comorbidity) with length of stay < 3 days

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 DRG 244: Permanent Cardiac Pacemaker Implant without Complications/Comorbidity (CC) / Major Complication/Co morbidity (MCC) with length of stay < 3 days

 DRG 251: Percutaneous Cardiovascular Procedure without Coronary Artery Stent without Major Complication/Comorbidity (MCC) with length of stay < 3 days

 DRG 287: Circulatory Disorders except AMI with Cardiac Cath without Major Complication/Comorbidity (MCC) with length of stay < 3 days

 DRG 470: Major joint replacement or reattachment of lower extremity without MCC with length of stay < 3 days  DRG 673: Other Kidney and Urinary Tract Procedures with Major Complication/Comorbidity (MCC) with length

of stay < 3 days

 DRG 714: Transurethral Prostatectomy without Complication/Comorbidity(CC) / Major Complication/Comorbidity (MCC) with length of stay < 3 days

Novitas’ Service Wide (Widespread) Edits (Jurisdiction L):

PLEASE NOTE: THE FOLLOWING EDITS HAVE ALL BEEN SUSPENDED

 DRG 227: Cardiac Defibrillator Implant without cardiac cath without Major Complication/Co morbidity (MCC) with length of stay < 3 days

 DRG 243: Permanent Cardiac Pacemaker Implant with CC (Complications/Comorbidity) with length of stay < 3 days

 DRG 244: Permanent Cardiac Pacemaker Implant without Complications/Comorbidity (CC) / Major Complication/Co morbidity (MCC) with length of stay < 3 days

 DRG 292: Heart Failure and Shock with CC with length of stay < 3 days  DRG 313: Chest Pain with length of stay < 3 days

 DRG 392: Esophagitis, Gastroenteritis and Miscellaneous Digestive D/O w/o MCC with length of stay < 3 days  DRG 470: Major joint replacement or reattachment of lower extremity without MCC with length of stay < 3 days  DRG 551: Medical back problems with MCC with length of stay < 3 days

 DRG 552: Medical back problems without MCC with length of stay < 3 days

 DRG 714: Transurethral prostatectomy without CC/MCC with length of stay < 3 days Novitas website: https://www.novitas-solutions.com/parta/index.html

Palmetto Government Benefit Administrators

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Wisconsin Physicians Service

Wisconsin Physician Services (WPS) has indicated a number of service-specific (prepay) edits. WPS’ current prepay edits include the following:

 48 hour Observation – Reason Code: E51#L  High Dollar Claims – Reason Code: 50BMM

 Inpatient Rehabilitation Facility (IRF) – Reason Code: 50IRF  Long Term Acute Care Hospital (LTCH) – Reason Code: 5LTCH

 Short Term Acute Care Hospital (STCH) – Reason Code: 5NERV, 50ENT, 5 RESP, 5CIRC, 5DIGS, 5PANC, 5MUSC, 5SKIN, 5GLND, 5KIDN, 5HEAL

The complete list of WPS’ current service-specific prepay edits can be found at:

http://www.wpsmedicare.com/j5macparta/departments/medical_review/index.shtml#PPE.

WPS website: http://www.wpsmedicare.com/j5macparta/index.shtml (J5 MAC Part A) and

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Recovery Auditor Updates

The Recovery Auditor Prepayment Review Demonstration began in August 2012. The demonstration is applicable to seven HEAT states (California, Florida, Illinois, Louisiana, Michigan, New York, and Texas) and four states (Missouri, North Carolina, Ohio, and Pennsylvania)

The following information was recently posted on the Recovery Auditor Program Recent Updates page on the CMS website:

May 1, 2014 – The following information is intended to notify providers of current Recovery Auditors’ activities after June 1, 2014.

As noted in previous updates, the last day that Recovery Auditors may send claim adjustment files to the Medicare Administrative Contractors (MAC) is June 1, 2014. As of June 2, 2014, only claim closure files may be sent to the MACs, by the Recovery Auditor.

Because no additional reviews will occur under the current contracts, current Recovery Auditors will not be required to update the “New Issue” (“Approved Issue”) portion of their websites, as of June 2, 2014. However, Recovery Auditors shall continue to update the “Claims Status” portion of their provider portal, in a timely manner, until further notice.

Recovery Auditors shall complete all Discussion Periods that are underway as of June 1, 2014. Recovery Auditors shall continue to accept new Discussion Period requests until June 30, 2014. All Discussion Periods initiated during June shall be completed. Recovery Auditors shall not accept new Discussion Period requests after July 1, 2014.

Recovery Auditors shall continue to maintain their customer service areas (telephone lines and appropriately training staff) and process for escalating concerns, until further notice.

Recovery Auditors shall continue to support the appeal process.

Note: Medicare Administrative Contractor (MAC) processes will continue. Therefore, claims sent for adjustment, by a Recovery Auditor, on or before June 1, 2014 may complete the adjustment process on, or after, June 2, 2014. The Medicare Appeals process will also continue. Therefore, recoupments can occur, if a provider does not file a timely appeal (to the 1st or 2nd level of appeal), or receives an “unfavorable” decision at the 2nd level (QIC) of the appeals process.

Recovery Audit Program Pause on Sending Additional Documentation Requests to Providers

CMS recently announced a pause in the Recovery Audit program in order to transition down the current contracts in anticipation of awarding the next round of Recovery Audit program contracts within the next few months. The following are some important dates:

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 February 21 is the last day a Recovery Auditor may send a postpayment Additional Documentation Request (ADR)

 February 28 is the last day a MAC may send prepayment ADRs for the Recovery Auditor Prepayment Review Demonstration

 June 1 is the last day a Recovery Auditor may send improper payment files to the MACs for adjustment

New Approved RAC Issues

Performant Recovery – Region A

No new Part A approved issues at this time.

Performant will be performing the Recovery Auditor Prepayment Review Demonstration in the following states:  New York

 Pennsylvania

Performant Recovery website: https://www.dcsrac.com/IssuesUnderReview.aspx

CGI – Region B

CGI will be performing the Recovery Auditor Prepayment Review Demonstration in the following states:  Illinois

 Michigan  Ohio

CGI website: https://racb.cgi.com/Issues.aspx

Connolly – Region C

On February 10, 2014, the following issue was approved for audit:  Medical Necessity: Percutaneous Transluminal Angioplasty

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On February 4, 2014, the following issue was approved for audit:  Hospice: Medicare Coverage Requirement Review

Connolly will be performing the Recovery Auditor Prepayment Review Demonstration in the following states:  Florida

 Louisiana  Texas

 North Carolina

Connolly website: http://www.connolly.com/healthcare/pages/ApprovedIssues.aspx

HDI – Region D

HDI will be performing the Recovery Auditor Prepayment Review Demonstration in the following states:  California

 Missouri

HDI website: https://racinfo.healthdatainsights.com/Public1/NewIssues.aspx

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