As part of our prevention efforts, CMS introduced new Medicare Part D opioid safety policies to reduce prescription opioid misuse while preserving medically necessary access to these medications. It’s important to note that these new policies are not “one size fits all,” and are deliberately tailored to address distinct populations of Medicare Part D prescription opioid users. These interventions do not apply to residents of long-term care facilities, beneficiaries in hospice, palliative, or end-of-life care, and beneficiaries being treated for active cancer-related pain.

The new Medicare Part D opioid policies encourage collaboration and care coordination among Medicare drug plans, pharmacies, prescribers, and patients in order to improve opioid management, prevent opioid misuse, and promote safer prescribing practices.

For More Information:

Roadmap (PDF)
Prescriber’s Guide to New Medicare Part D Opioid Overutilization Policies for 2019 (PDF) MLN Matters Article
Training materials for prescribers (ZIP), pharmacists (ZIP), and patients (ZIP)

See the full text of this excerpted CMS Blog (issued March 28).

“Qué está Cubierto”

On March 21, CMS released an updated version of the Medicare “What’s Covered” app that includes Spanish. “Qué está Cubierto” lets people with original Medicare, caregivers, providers, and others quickly see whether Medicare covers a specific medical item or service. You can now use your mobile device to more easily get accurate, consistent original Medicare coverage information in your office, the hospital, or anywhere. The free app is available in Google Play - Opens in a new window and the Apple App Store - Opens in a new window .

Physician Compare: Supplemental Preview Period Open until April 27

CMS is offering a supplemental Physician Compare preview period through April 27 with the latest 2017 performance information. Eligible clinicians and groups: Check your information by logging into the Quality Payment Program website.

For More Information:

Preview Period User Guide (PDF)
from the October Medicare Learning Network webcast
Physician Compare Initiative website
Clinician Information: Performance Year 2017 Preview Period (PDF)
Group Information: Performance Year 2017 Preview Period (PDF)
For assistance accessing the Quality Payment Program website or obtaining your user role, contact
For questions about Physician Compare, public reporting, or the preview period, contact

Open Payments: Review and Dispute Data by May 15

Pre-publication review and dispute for program year 2018 Open Payments data is available through May 15. CMS will publish program year 2018 data and updates to the previous program years’ data in June. Physician and teaching hospital review of the data is voluntary, but strongly encouraged:

Records eligible for review and dispute: All records submitted during the submission period of the current calendar year, including newly edited, submitted, and re-attested records from previous calendar years; See the Physician and Teaching Hospital Review and Dispute Tutorial (PDF)
Disputes must be initiated by May 15: See the Review and Dispute Timing and Data Publication Quick Reference Guide (PDF)
CMS does not meditate or facilitate disputes: Work directly with reporting entities to resolve disputes
Registration in the Open Payments system is required: Visit the Registration for Physicians & Teaching Hospitals webpage for instructions

If you are already registered, log in to review your data:

If you have not accessed your account in 60 days or more, you will need to unlock your account in the CMS Portal
If you have not accessed your account in 180 days or more, your account has been deactivated, and you will need to contact the Open Payments Help Desk to reinstate your account

For More Information:

Open Payments website
from March 13 Medicare Learning Network call
Contact the Open Payments Help Desk at or 855-326-8366; TTY 844-649-2766

Comparative Billing Report on Subsequent Hospital Visits

In late March, CMS issued a Comparative Billing Report (CBR) on Subsequent Hospital Visits. The CBR, produced by RELI Group, focuses on rendering providers who submit Medicare Part B claims. These reports contain data-driven tables with an explanation of findings that compare your billing and payment patterns to those of your peers in your state and across the nation.

CBRs are not publicly available. Look for an email from with your report. Update your contact email address in the National Plan and Provider Enumeration System to ensure accurate delivery.

For More Information:

Visit the CBR "> CBR - Opens in a new window website
Register - Opens in a new window for the webinar on April 11

PEPPERs for Hospices, LTCHs, SNFs, IRFs, IPFs, and CAHs,

Fourth quarter FY 2018 Program for Evaluating Payment Patterns Electronic Reports (PEPPERs) are available for hospices, Long-Term Care Hospitals (LTCHs), Skilled Nursing Facilities (SNFs), Inpatient Rehabilitation Facilities (IRFs), Inpatient Psychiatric Facilities (IPFs), and Critical Access Hospitals (CAHs). These reports summarize provider-specific data statistics for Medicare services that may be at risk for improper payments. Use your data to support internal auditing and monitoring activities.

Hospices, LTCHs and free-standing SNFs and IRFs: For instructions on obtaining your PEPPER, see the Secure PEPPER Access Guide - Opens in a new window
IPFs, and SNF and IRF units of hospitals: PEPPER was distributed via the QualityNet secure portal
CAHs: Your PEPPER delivery method is changed; see the CAH section of the PEPPER Resources - Opens in a new window website

For More Information:

Visit the PEPPER Resources - Opens in a new window website for guides, recorded training sessions, QualityNet account information, frequently asked questions - Opens in a new window , and examples of how other hospitals are using the report
Visit the Help Desk - Opens in a new window if you have questions or need help obtaining your report
Send us your feedback or suggestions - Opens in a new window

Hospice Visits when Death is Imminent Measure Pair

The Hospice Visits when Death is Imminent measure pair assess whether a hospice patient and caregiver’s needs were addressed by hospice staff in the last three and seven days of life:

3-day measure will be publicly reported on Hospice Compare in summer 2019, as planned
7-day measure will not be publicly reported at this time because it does not meet readiness standards for public reporting

For More Information:

Mapping Medicare Disparities Tool: New Enhancements

CMS expanded the Mapping Medicare Disparities (MMD) Tool Population View to include several new enhancements:

Data by rural and urban areas: View and compare health outcome, spending, and utilization rates across rural and urban counties
Four opioid use disorder indicators: View prevalence, cost, and utilization rates
2017 data

Why use our MMD Tool? You can view and download maps and data files to learn more about health outcomes in your community. The web-based tool provides health outcome measures for disease prevalence, costs, and hospitalization for 55 specific chronic conditions, emergency department utilization, readmissions rates, mortality rates, and preventable hospitalizations. View your hospital’s metric and performance score across more than 50 quality measures and compare hospitals based on geography, hospital type, and/or hospital size.

If you have questions, email .

Medicare-Medicaid Crossover Bad Debt Accounting Classification

Providers claiming Medicare bad debt must meet 42 CFR 413.89 and all requirements from Chapter 3 of the Provider Reimbursement Manual (ZIP). Correctly classify unpaid deductible and coinsurance amounts for Medicare-Medicaid crossover claims in your accounting records. For bad debt amounts:

Do not write off to a contractual allowance account
Charge to an expense account for uncollectible accounts (bad debt)

Effective for cost reporting periods beginning on or after October 1, 2019, providers must comply with these longstanding Medicare bad debt requirements.

Qualified Medicare Beneficiary Billing Requirements

Are you in compliance with Qualified Medicare Beneficiary (QMB) billing requirements? People with Medicare who are in the QMB program are also enrolled in Medicaid and get help with their Medicare premiums and cost-sharing. Medicare providers may not bill people in the QMB program for Medicare deductibles, coinsurance, or copays, but state Medicaid programs may pay for those costs. Providers who inappropriately bill individuals enrolled in QMB are subject to sanctions.

Establish processes to routinely identify the QMB status of Medicare beneficiaries prior to billing for items and services:

Use Medicare 270/271 HIPAA Eligibility Transaction System (HETS) data; see MLN Matters® Article SE1128 (PDF)
Check your Medicare Remittance Advices (RAs); see MLN Matters Article MM10433 (PDF)
Check state automated Medicaid eligibility-verification systems

States require providers to enroll in their Medicaid systems for claim review, adjudication, processing, and issuance of Medicaid RAs for payment of Medicare cost-sharing. Check with the states where your beneficiaries reside to determine the enrollment requirements.

Correct billing problems that occur. If you erroneously bill individuals enrolled in the QMB program, recall the charges (including referrals to collection agencies) and refund the invalid charges they paid.

For More Information:

QMB Program webpage
Prohibition on Billing Dually Eligible Individuals Enrolled in the QMB Program (PDF) MLN Matters Article
QMB Program Billing Requirements FAQs (PDF)
from 2018 Medicare Learning Network call
Dual Eligible Beneficiaries under the Medicare and Medicaid Programs (PDF) Booklet

National Minority Health Month: Active & Healthy

April is National Minority Health Month—a time to highlight the health disparities that persist among racial and ethnic minority populations and the ways we can continue the path towards equity. This year’s theme raises awareness about the importance of an active lifestyle.

Many minorities experience a disproportionate burden of preventable disease, including diabetes, heart disease, kidney failure, and obesity. Talk to your patients about the importance of preventive care and recommend appropriate Medicare-covered preventive services.

For More Information:

Educational Tool
From Coverage to Care webpage, including A Roadmap to Behavioral Health (PDF): Help your patients navigate their health care, understand their benefits, and seek preventive services
Mapping Medicare Disparities Tool: CMS added data by rural and urban areas, four opioid use disorder indicators, and an updated the Population View with 2017 data
Connected Care: The Chronic Care Management Resource webpage, including the Connected Care Toolkit (PDF): Support Medicare patients with chronic diseases; Provide chronic care management services, which is care coordination outside of the regular office visit for patients with two or more chronic conditions
Guide to Developing a Language Access Plan (PDF) and Providing Language Services to Diverse Populations: Lessons from the Field (PDF): Help ensure patients with limited English proficiency have access to services
Disparities Impact Statement (PDF) Worksheet: Identify, prioritize, and take action on health disparities; receive personalized help strengthening your quality improvement and disparities reduction work by emailing
HHS National Minority Health Month webpage

Visit the Preventive Services website to learn more about Medicare-covered services.

Looking for Educational Materials?

Visit the Medicare Learning Network and see how we can support your educational needs. Learn about publications; calls and webcasts; continuing education credits; Web-Based Training; newsletters; and other resources.

Compliance

Coding for Specimen Validity Testing Billed in Combination with Urine Drug Testing

In a February 2018 report, the Office of the Inspector General (OIG) determined that Medicare payments to clinical laboratories and providers for specimen validity tests did not comply with Medicare billing requirements. This MLN Matters Special Edition Article (PDF) reminds laboratories and other providers about proper billing for specimen validity testing done in conjunction with drug testing; this article contains no policy changes.

Current coding for testing for drugs of abuse relies on a structure of presumptive and definitive testing that identifies the specific drug and quantity in the patient. This article includes descriptors for:

Presumptive drug testing codes
Definitive drug testing codes

Use the following resources to bill correctly and avoid overpayment recoveries:

Events

Comparative Billing Report: Subsequent Hospital Visits Webinar — April 11

Thursday, April 11 from 3 to 4 pm ET

Join us for a discussion of the Comparative Billing Report on Subsequent Hospital Visits (CBR201903), an educational tool for rendering providers who submit Medicare Part B claims. See the CBR - Opens in a new window website for more information.

MLN Matters® Articles

Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations

A new MLN Matters Article SE19007 on Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations (PDF) is available. Learn about requirements for Outpatient Prospective Payment System (OPPS) providers in the Medicare Claims Processing Manual, Chapter 1, Section 170.

ASP Medicare Part B Drug Pricing Files and Revisions: July 2019

A new MLN Matters Article MM11225 on July 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files (PDF) is available. Learn about the drug pricing files used to determine the payment limit for claims.

Changes to the Laboratory NCD Edit Software: July 2019

A new MLN Matters Article MM11224 on Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2019 (PDF) is available. Learn about coding updates.

Correction to FY 2019 IPPS Pricer

A new MLN Matters Article MM11208 on Correction of the Fiscal Year (FY) 2019 Inpatient Prospective Payment System (IPPS) Pricer (PDF) is available. Learn about adjustments.

FY 2017 SSI/Medicare Beneficiary Data for IPPS Hospitals, IRFs, LTCHs

A new MLN Matters Article MM11187 on The Supplemental Security Income/Medicare Beneficiary Data for Fiscal Year 2017 for Inpatient Prospective Payment System Hospitals, Inpatient Rehabilitation Facilities, and Long Term Care Hospitals (PDF) is available. Learn about changes and adjustments to Supplemental Security Income (SSI)/Medicare beneficiary data for Inpatient Prospective Payment System (IPPS) hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long-Term Care Hospitals (LTCHs).

NCCI PTP Edits: Quarterly Update

A new MLN Matters Article MM11227 on Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.2 Effective July 1, 2019 (PDF) is available. Learn about updates and edits.

E/M and Superficial Radiation Treatment — Revised

A revised MLN Matters Article MM11137 on Evaluation and Management (E/M) When Performed with Superficial Radiation Treatment (PDF) is available. Learn about changes to billing for superficial radiation treatment.

Publications

Understanding the Medicare Beneficiary Identifier

A new Medicare Learning Network Educational Tool is available. Post this one pager on your desk for easy reference. Learn about:

Alpha and numeric characters
Letters never used to avoid confusion

Acute Care Hospital Inpatient Prospective Payment System — Revised

A revised Medicare Learning Network Booklet is available. Learn about:

Payment rates and updates
How payments are set

Hospice Payment System — Revised

A revised Medicare Learning Network Booklet is available. Learn about:

Coverage and certification requirements
Election periods and statements
Caps on payments

Ambulatory Surgical Center Payment System — Revised

A revised Medicare Learning Network Booklet is available. Learn about:

Payment rates and methods
Where to submit bills

Medicare Preventive Services — Revised

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

Codes
Coverage information

Multimedia

Reducing Opioid Misuse Call: Audio Recording and Transcript

An audio recording (ZIP), transcript (PDF), and clarification (PDF) are available for the Medicare Learning Network call on the New Part D Opioid Overutilization Policies. Learn about the new policies for Medicare drug plans effective January 1.

Promoting Interoperability Call: Audio Recording and Transcript

An audio recording (ZIP) and transcript (PDF) are available for the Medicare Learning Network call on Data Interoperability across the Continuum. Learn about the recently released CMS Data Element Library, a database of post-acute care patient assessment content.

SNF Value-Based Purchasing Program Call: Audio Recording and Transcript

An audio recording (ZIP) and transcript (PDF) are available for the Medicare Learning Network call on Skilled Nursing Facility (SNF) Value-Based Purchasing Program Phase One Review and Corrections. Learn about the process and get answers to frequently asked questions.

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