Thursday, September 9, 2021
- PEPPERs for Short-term Acute Care Hospitals
- Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments: Payment Update
- Prostate Cancer: Talk to Your Patients about Screening
View this edition as PDF (PDF)
News
PEPPERs for Short-term Acute Care Hospitals
Second quarter fiscal year 2021 Program for Evaluating Payment Patterns Electronic Reports (PEPPERs) are available for short-term acute care hospitals. These reports summarize provider-specific data for Medicare services that may be at risk for improper payments. Use your data to support internal auditing and monitoring activities. CMS recently distributed your report through the PEPPER Resources Portal.
More Information:
- Visit the PEPPER Resources website for user's guide, recorded training sessions, FAQs, and examples of how other hospitals are using the report
- Register for a webinar on September 15 from 3-4 pm ET
- Contact the Help Desk if you have questions or need help obtaining your report
- Send us your feedback or suggestions
Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments: Payment Update
By November 1, 2021, CMS will begin reprocessing claims for outpatient clinic visit services provided at excepted off-campus Provider-Based Departments (PBDs) so they’re paid at the same rate as non-excepted off-campus PBDs for those services under the Physician Fee Schedule (PFS). This affects certain claims with dates of service between January 1 - December 31, 2019. You don’t need to do anything; we’ll reprocess all affected claims. You must refund the coinsurance difference to patients (or payers) who paid the higher coinsurance rates based on new remittance advice information.
Background:
- November 21, 2018: The Calendar Year (CY) 2019 Outpatient Prospective Payment System (OPPS) Rule finalized payment for certain outpatient clinic visit services provided at excepted off-campus PBDs at the same rate that we pay non-excepted off-campus PBDs for those services under the PFS. Previously, CMS and Medicare patients often paid more for the same type of clinic visit in the hospital outpatient setting than in the physician office setting.
- In 2019: We reduced payment to 70% of the full OPPS rate in off-campus PBDs. In 2020, this rate changed to 40%.
- September 17, 2019: The U.S. District Court for the District of Columbia declared invalid the CY 2019 payment rule that provided for the reduction for clinic visits provided at excepted off-campus PBDs.
- January 1 – July 2020: We reprocessed CY 2019 claims paid at the reduced payment rate of 70% to restore the 100% payment rate in accordance with the district court decision.
- July 17, 2020: The U.S. Court of Appeals for the D.C. Circuit reversed the district court ruling, upholding our volume control site-neutrality payment policy for off-campus outpatient hospital clinic visits.
Prostate Cancer: Talk to Your Patients about Screening
Medicare covers prostate cancer screenings. During Prostate Cancer Awareness Month, talk to your patients about the nature and risk of prostate cancer, and help them make an informed decision about screening.
More Information:
- Preventive Services webpage
- CDC Prostate Cancer webpage
- National Cancer Institute Prostate Cancer webpage
- Information for your patients on prostate cancer screenings
Compliance
DMEPOS Items: Medical Record Documentation
For Medicare to cover any Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) item, the patient’s medical record must include enough documentation to justify the need for
- Type and quantities of items ordered
- Frequency of use (or replacement if applicable)
The medical record should include the patient’s diagnosis and:
- Duration of the condition
- Clinical course (worsening or improving)
- Prognosis
- Nature and extent of functional limitations
- Other therapeutic interventions and results
- Experience with related items
The medical record may include records from hospitals, nursing facilities, home health agencies, and other health care professionals.
For more information, see the Medicare Program Integrity Manual, Chapter 5 (PDF), Section 5.9.
Events
Medicare Ground Ambulance Data Collection System: Q&A Session — September 14
Tuesday, September 14 from 2-3 pm ET
Do you have questions about the Medicare Ground Ambulance Data Collection System? Join this live Q&A session. You may also send questions in advance to AmbulanceDataCollection@cms.hhs.gov with “September 14 Q&A” in the subject line. We’ll update documents on our Ambulances Services Center webpage with answers to common questions from this session.
More Information:
- Ambulances Services Center webpage: Includes lists of organizations that must collect data starting in 2022
- Calendar Year (CY) 2022 Physician Fee Schedule (PFS) proposed rule
- CY 2020 PFS final rule
MLN Matters® Articles
Medicare FFS Response to the PHE on the COVID-19 — Revised
- Emergency measures don’t waive or change any other existing coverage requirements
- CMS is monitoring admissions under section 1812(f) that don’t meet level of care criteria and taking administrative action
Publications
Medicare Mental Health — Revised
Read new information (PDF) in this Medicare Learning Network booklet to clarify:
- Information on eligible professionals, including certified registered nurse anesthetists
- Coverage and payment requirements
- Incident to provision
Multimedia
SNF Consolidated Billing Web-Based Training — Revised
See updated information in this Medicare Learning Network (MLN) web-based training course:
- Coverage and payment guidelines
- Services in a non-covered Part B stay
- Agreements between Skilled Nursing Facilities (SNFs) and other providers
- Excluded Part A SNF consolidated billing services.
Visit the MLN Web-Based Training webpage for a current list of courses.
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