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

See the MLN Matters Article (PDF) to learn how to get and use MBIs.

IRF/LTCH/SNF Quality Reporting Program: Submission Deadline Extended to November 18

The submission deadline for the Inpatient Rehabilitation Facility (IRF), Long-Term Care Hospital (LTCH), and Skilled Nursing Facility (SNF) Quality Reporting Programs is November 18 for second quarter 2019 data:

IRF- Patient Assessment Instrument (PAI) and LTCH Continuity Assessment Record and Evaluation (CARE) assessment data and data submitted to CMS via the Center for Disease Control and Prevention National Healthcare Safety Network
Minimum Data Set (MDS) data

List of Measures:

IRF Quality Reporting Data Submission Deadlines webpage
LTCH Quality Reporting Data Submission Deadlines webpage
SNF Quality Reporting Program Data Submission Deadlines webpage

CMS recommends that you run analysis reports prior to each quarterly reporting deadline to make sure all required data is submitted.

MIPS Heart Failure Measure: Call for Public Comment Closes November 27

CMS is developing a measure of acute cardiovascular-related admissions for patients with heart failure for the Merit-based Incentive Payment System (MIPS). Visit the Public Comment webpage for more information, and find out how to submit your comments.

CAHs: Hardship Exception Application Deadline December 2

CMS requires that all Critical Access Hospitals (CAHs) use either the 2014 or 2015 Edition Certified Electronic Health Record Technology (CEHRT) to meet the reporting requirements of the Medicare Promoting Interoperability Program and successfully demonstrate meaningful use. CAHs may avoid the Medicare downward payment adjustments if they can show that meeting these requirements would result in a significant hardship. To be considered for an exception, you must complete a hardship exception application by December 2 and select the reason for the hardship.

For More Information:

Submit your application over the phone by calling the QualityNet Help Desk at 866-288-8912

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.

MIPS: Virtual Group Election Period Open Through December 31

To form a virtual group for the 2020 Merit-based Incentive Payment System (MIPS) performance year, you must follow an election process and submit your election to CMS via email by December 31.

For More Information:

2020 Virtual Groups Toolkit - Opens in a new window
Contact QPP@cms.hhs.gov or 866-288-829 (TTY: 877-715-6222)

Medicare Ground Ambulance Data Collection System: Starts January 1, 2020

Beginning January 1, CMS requires selected ground ambulance organizations to collect and report cost, revenue, utilization, and other information through a Ground Ambulance Data Collection System. The data will be analyzed to assess the adequacy of Medicare payment rates for ground ambulance services.

More than 2,600 randomly selected Medicare rural health ground ambulance organizations make up the initial group. Other randomly selected Medicare ground ambulance organizations will be selected each year from 2020-2024.

For More Information:

Ambulances Services Center website: List of selected organizations, webinars, and other resources
Register - Opens in a new window for Medicare Learning Network call on December 5

Home Health Agency: Final OASIS D-1 Data Submission Specifications

Final Outcome and Assessment Information Set (OASIS) D-1 data submission specifications (ZIP) are available on the webpage, including required changes to support transition to the Patient-Driven Groupings Model. The new version, V2.31.0, is effective for assessments with a completion date of January 1, 2020 or later.

MACRA Patient Relationship Categories and Codes: Learn More

MACRA Patient Relationship Categories (PRCs) and codes facilitate the attribution of patients and care episodes to clinicians who serve patients in different roles as part of the assessment of the cost of care. When tested, the PRCs may be incorporated into the claims-based cost measures, which assess the beneficiary's total cost of care during the year, or during a hospital stay, and/or during eight episodes of care. CMS finalized five patient relationship categories for use in a voluntary reporting period, which began January 1, 2018. Read the FAQ document - Opens in a new window to learn more.

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 requires the establishment and use of patient relationship categories and codes.

Recommend Influenza Vaccination: Each Office Visit is an Opportunity

People 65 years and older are at high risk of developing serious influenza-related complications. The Centers for Disease Control and Prevention (CDC) recommends annual influenza vaccination for everyone 6 months and older. Your strong vaccine recommendation is a critical factor that affects whether your patients get an influenza vaccine. Take time to recommend and vaccinate 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:

Educational Tool
Influenza Resources for Health Care Professionals (PDF) MLN Matters Article
Influenza Vaccine Payment Allowances (PDF) MLN Matters Article
CDC Influenza website
CDC Information for Health Professionals webpage
CDC Fight Flu Toolkit webpage

Compliance

Bill Correctly for Medicare Telehealth Services

In a recent report, the Office of Inspector General (OIG) determined that the Centers for Medicare & Medicaid Services (CMS) improperly paid practitioners for some telehealth claims associated with services that did not meet Medicare requirements. CMS released the Medicare Telehealth Services - Opens in a new window Video to help you bill correctly. Additional resources:

Telehealth Services (PDF) Medicare Learning Network Booklet
Medicare Claims Processing Manual, Chapter 12 (PDF), Section 190
Medicare Telehealth Payment Eligibility Analyzer
List of Covered Telehealth Services webpage
CMS Paid Practitioners for Telehealth Services That Did Not Meet Medicare Requirements OIG Report

Claims, Pricers & Codes

Skilled Nursing Facility Claims Hold

As CMS has undertaken the implementation of the Patient Driven Payment Model (PDPM), we are holding a limited number of Skilled Nursing Facility (SNF) claims while we make further refinements to our claims processing system.

PDPM is a historic reform of the SNF prospective payment system. PDPM focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment. PDPM was effective on October 1, 2019.

Specifically, CMS is holding claims with:

Dates of service October 1, 2019 or later and
Type of Bill (TOB) inpatient services (21X) and swing bed services (18X) subject to SNF Patient Driven Payment Model (PDPM) and
Multiple line items, Health Insurance Prospective Payment System (HIPPS) codes, with different rate codes (revenue code 0022).

Typically, SNFs bill these claims on monthly cycles. Claims with single HIPPS codes were previously being held but are now being released for processing. We anticipate releasing the remaining held claims in late November, once CMS completes systems testing to ensure accurate and timely payment. As of November 1, less than 50 claims are being held.

In addition, we underpaid some SNF inpatient services (21X) and swing bed services (18X) claims for dates of service in October 2019 with a single line item, single HIPPS code. We are automatically reprocessing those claims; no provider action is needed.

CMS will continue to provide updates as further information develops.

Events

Clinical Diagnostic Laboratory Test Payment System: Data Reporting Call — November 14

Thursday, November 14 from 2 to 3 pm ET

During this call, learn how to report data required by the Clinical Diagnostic Test Payment System final rule (PDF). CMS demonstrates how to register in the system and submit then certify data. Laboratories, including physician offices laboratories and hospital outreach laboratories that bill using a 14X TOB are required to report laboratory test HCPCS codes, associated private payor rates, and volume data if they:

Have more than $12,500 in Medicare revenues from laboratory services on the Clinical Laboratory Fee Schedule (CLFS), and
Receive more than 50 percent of their Medicare revenues from CLFS and physician fee schedule services during a data collection period

CMS will use this data to set Medicare payment rates effective January 1, 2021. For more information, visit the PAMA Regulations webpage.

A question and answer session follows the presentation; however, you may email questions in advance to CLFS_Inquiries@cms.hhs.gov with “November 14 Call” in the subject line. These questions may be addressed during the call or used for other materials following the call.

Target Audience: Clinical diagnostic laboratories, including physician offices and hospital outreach laboratories.

Ground Ambulance Organizations: Data Collection System Call — December 5

Thursday, December 5 from 1:30 to 3 pm ET

During this call, get an overview of the new Ground Ambulance Data Collection system, including:

Background
Selection of organizations required to report
Detailed discussion of the Data Collection Instrument

A question and answer session follows the presentation; however, you may email questions in advance to AmbulanceDataCollection@cms.hhs.gov with “December 5 Call” in the subject line. These questions may be addressed during the call or used for other materials following the call. For more Information, including providers selected for the first round of reporting, see the Ambulance Services Center webpage, CY 2020 Physician Fee Schedule final rule, and Bipartisan Budget Act of 2018.

Target Audience: Ground ambulance organizations and ambulance stakeholders.

MLN Matters® Articles

Addition of Medical Severity Diagnosis Related Groups (MS-DRG) Subject to Inpatient Prospective Payment System (IPPS) Replaced Devices Offered Without Cost or With a Credit Policy

A new MLN Matters Article MM11508 on Addition of Medical Severity Diagnosis Related Groups (MS-DRG) Subject to Inpatient Prospective Payment System (IPPS) Replaced Devices Offered Without Cost or With a Credit Policy (PDF) is available. Learn about the addition of MS-DRGs 319 and 320.

Health Professional Shortage Area (HPSA) Bonus Payments for All Mental Health Specialties

A new MLN Matters Article MM11327 on Health Professional Shortage Area (HPSA) Bonus Payments for All Mental Health Specialties (PDF) is available. Learn about psychiatric specialties eligible to receive the mental health bonus.

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.0, Effective January 1, 2020

A new MLN Matters Article MM11523 on Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.0, Effective January 1, 2020 (PDF) is available. Learn about coding policies and where to find additional information.

April 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) — Revised

A revised MLN Matters Article MM11216 on April 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) (PDF) is available. Learn about revisions related to Chimeric Antigen Receptor (CAR) T- Cell Therapy.

Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System — Revised

A revised MLN Matters Article MM11003 on Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System (PDF) is available. Learn about eMDR registration and enrollment.

Publications

Opioid Treatment Programs (OTPs) Medicare Enrollment

A new Medicare Learning Network Fact Sheet is available. Learn about:

Pre-enrollment steps
How to submit your application
What to expect after you submit your application
Enrollment process checklist

Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B — Revised

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

Billing information
Frequently asked questions
Codes
Descriptors

Multimedia

Medicare Telehealth Services Video

A new Medicare Telehealth Services Medicare Learning Network Video is available. Learn about:

Who can furnish services
Qualifications for an originating site
Covered services
Billing and payment

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