Current Developments

Click on the dates below to view PDF versions of past issues of the monthly Current Developments newsletter.

• The December 2010 issue includes:
• The 2011 additional documentation limits for RACs
• Contractors requesting mandatory ABNS with documents
• New G codes for annual wellness visit
• New flu vaccine codes
• Clarification on NaF-18 PET billing
• 2011 lab specimen collection and travel allowance fees
• Implementation of ACA “incentive Payment for Physician Services”
• 2011 reasonable charge update for splints, casts, and certain intraocular lenses
• Chart of Rescinded and Replaced Transmittals
• And a special article “Surviving the Government Oversight and Enforcement Activities in the Coming Year”

• The November 2010 issue includes:
  • A summary of changes in the final 2011 OPPS/ASC rule, including the latest changes to physician supervision of outpatient diagnostic and therapeutic services
  • A summary of relevant provisions in the Medicare Physician Fee Schedule 2011 final rule
  • A table of the 2011 co-insurance and deductibles for Part A and Part B
  • Implementation of postacute care transfer policy for transfers to nonparticipating hospitals and CAHs
  • New requirements for coverage of therapy under the home health benefit
  • Use of condition code 51 to identify outpatient diagnostic services within the three-day window unrelated to the admission
  • And a special article on the cardiac defibrillator investigations, “MS-DRG 226 vs. 227: What Should Be on Your Radar?”

• The October 2010 issue includes:
  • Reviews on the FY 2011 OIG Work Plan with billing risks
  • CMS’ list of DRGs at high risk for medical necessity and coding errors based on the RAC demonstration project
  • CMS’ new quarterly compliance newsletter on billing
  • A Department of Justice investigation into cardiac defibrillator implants
  • New coverage for tobacco cessation programs and changes in the coverage for FDG PET and HSCT
  • The FY 2011 clotting factor
  • CMS and payer reminders on signature requirements for physician orders
  • And a special article on Condition Code 44

• The September 2010 issue includes:
  • Important CMS clarification on billing non-diagnostic services during the three-day window
  • Changes for the October OPPS and I/OCE
  • Partial freeze on ICD-9-CM updates beginning in Oct. 2011
  • Expanded coverage of quit smoking counseling
  • Automatic denials of claims with –JW modifier discontinued
  • List of transmittals implemented on Oct. 4
  • And a special article on Transitioning to HIPAA Version 5010 Electronic Transaction Standards

• The August 2010 issue includes:
  • Summary of policy changes in the Inpatient Prospective Payment System FY 2011 final rule, including a change in the acute care transfer policy, the three-day window, revised POA instructions, and for LTCH the two-year delay in a number of provisions mandated by the health care reform law.
  • Instructions on which date on the form determines whether the claim was timely filed
  • Revision to the IPF interrupted change policy
  • A new occurrence code to be used by SNFs and IRFs
  • First look at a comparative billing report
  • And a special article on The PPACA and Its Impact on Medicare Billing and Payment

• The July 2010 issue includes:
  • The revisions to the three-day window policy made by Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010, effective June 25
  • Summary of the proposed FY 2011 Outpatient Prospective Payment System/ASC rulemaking, including changes to physician supervision requirements and partial hospitalization services
  • The consolidation of the NCDs on magnetic resonance angiography and magnetic resonance imagery, which gives local contractors discretion regarding certain coverage
  • Reminder to IPFs to use source of admission code D
  • Availability of new ABN booklet
  • Proposed rules for home health for FY 2011 and physician payment policies for 2011 and payment updates for SNFs and IPFs for FY 2011
  • Plus a special article on Sanction Screening — Now an OIG High-Risk Priority

• The June 2010 issue includes:
  • CMS clarification of the meaning of “immediately available” for  the purpose of physician supervision
  • A summary of the July OPPS policy and the ASC payment system updates
  • Clarification of Medicare policies on audiological diagnostic tests
  • Two new NCDs and new codes to implement them
  • Summary of PPACA revisions that affect the IPPS/LTCH proposed rule
  • Proposed rule significantly revises telemedicine privileging and credentialing requirements
  • A special article explaining CMS’s recent updates to the self-administered drugs and discarded drugs in the Medicare manuals.

• The May 2010 issue includes:
• A summary of CMS’ proposal to extend the post-acute care transfer rule to nonparticipating hospitals and CAHs
• Release of the July OCE transmittal
• A revised definition of the term “administered” for purposes of self-administered drug determinations
• Implementation of new timely filing limits
• Addition of pulmonary rehabilitation benefit and coding/billing requirements to Medicare manuals
• Deadline (with consequences) for submitting certain data for Medicare Advantage patients
• New requirements for health care professionals and suppliers who order and furnish certain items and services
• Update to the amount in controversy for Medicare appeals
• A new bill type in October for colorectal screenings for hospital inpatients under Part B

• The April 2010 issue includes:
• A preview of the FY 2011 IPPS/LTCH proposed rule
• CMS’ new Web address
• Provisions in the health care reform legislation affecting hospitals and other providers
• Addition of an ICD-9-CM code to the list of codes for implantable cardiac defibrillator that do not require a modifier retroactive to Oct. 1, 2007
• New CMS initiative to centralize all Medicare claims data
• New Open Government initiatives by CMS — Medicare Dashboard and free data files
• New coverage and billing requirements for use of NaF-18 PET for cancer patients
• Billing for patients “in custody”
• Table of CMS transmittals rescinded and replaced in March
• Plus a special article on the Three-Day Window Rule, which is once again an area for auditor review

• The March 2010 issue includes:
• A summary of the April OPPS and I/OCE transmittals
• New RAC Q&A distinguishing the discussion period from the rebuttal and determination process
• New coverage and billing requirements for HIV screening tests
• Coding and billing instructions for drug screening lab codes 80100 and 80101
• Revival of the therapy cap exceptions process
• Change in reporting of occurrence span codes for beneficiaries in extended stays in LTCHs, IPFs, and IRFs
• Table of CMS transmittals rescinded and replaced in March
• Table of CMS transmittals to be implemented in April
• A list of the new and revised risk areas on the Web site
• Plus a special article on the new ABN modifiers that take effect on April 1

• The February 2010 issue includes:
  • RACs add more DRGs for validation
  • The release of PEPPER data
  • The rescission of the policy on date of service and place of service reporting for the interpretation of diagnostic tests
  • National coverage determination for OIVIT
  • Billing a healthy control group in a clinical trial
  • New data reporting for ESRD facilities
  • New billing rules for hospices
  • Plus a special article on DRG Validation: Staying One Step Ahead of the RACs

• The January 2010 issue includes:
  • The revival of PEPPER
  • Update on approved RAC issues
  • Billing instructions for new kidney disease education
  • Updates on telehealth billing and the telehealth site facility fee
  • Plus a special article on Billing for Outpatient Therapy Services in 2010, which highlights a shift in policy for physician supervision

• The December 2009 issue includes:
  • A summary of the OPPS transmittal and I/OCE for January, which implement many of the changes from the final rule
  • Revisions to the Medicare Benefit Policy Manual to reflect the revised physician supervision provisions
  • A reminder that Medicare will no longer accept the CPT consulting codes
  • A notice from CMS that many providers are incorrectly reporting the wrong surgery modifiers and from the CERT contractor of billing for non-covered uses of dual chamber pacemakers
  • An NCD on Medicare coverage for FDG PET when used with patients with cervical cancer
  • And a special article, A Look at the RACs, Past, Present, and Future

• The November 2009 issue includes:
  • Summary of the policy changes in the final OPPS rule for 2010, including physician supervision and coverage of cardiac, intensive cardiac, and pulmonary rehabilitation programs
  • 2010 coinsurance and deductibles
  • New modifier for voluntary ABNs
  • Separate claims for inpatients with both covered and non-covered services
  • Phase-out of the mental health limitation over a five-year period
  • and a special article, “Protect Yourself: Know How to Bill Medicare for H1N1 and Seasonal Flu Vaccines to Prevent Revenue Loss”

• The October 2009 issue includes:
  • Highlights of the HHS OIG Work Plan for FY 2010
  • New audit areas for review based on four OIG reports
  • Important replacement transmittals for reporting surgical “never events” and FDG PET for solid tumors and myeloma
  • The Region A list of RAC issues
  • The amount in controversy thresholds for 2010
  • The final rule explaining how CMS will comply with the prohibition on recouping overpayments from a provider seeking reconsideration
  • And a special article on “Billing for Surgical ‘Never’ Events“

• The September 2009 issue includes:
• Summaries of the quarterly OPPS/ASC and I/OCE updates, eff. Oct. 1, which include new codes for the H1N1 vaccine
• Updated lists of the RAC-approved issues
• Announcement of the proposed PPS for ESRD facilities
• Revisions to both the Medicare Benefit and Claims Processing Manuals to incorporate the rules for billing for services rendered to individuals in custody
• Documentation problems found in a probe review of two common drugs
• A list of transmittals that will be implemented on Oct. 5
• and a special article, “Reporting E-Codes for Surgical ‘Never’ Events,” which are required Oct. 1

• The August 2009 issue includes:
• A summary of the final IPPS/LTCH rule for FY 2010
• The first round of RAC review areas
• Posting of revised Medicare cost report
• New point of origin codes
• CAH policy changes
• New billing for ambulance trips
• Release of HITECH breach notification rule
• And a special article, “Returning Improper Payments”

• The July 2009 issue includes:
  • A summary of the OPPS proposed rule for 2010
  • Major changes to coverage of FDG PET
  • Correction to the July OPPS update
  • New NCD for sleep testing devices
  • MLN Matters article on billing Part B or Part D for aprepitant
  • And a special article, “New Legal Exposure When You Fail to Repay Overpayments,” which discusses changes to the False Claims Act by the Fraud Enforcement and Recovery Act

• The June 2009 issue includes:
  • Summary of the July update to the OPPS
  • Status of the RAC program rollout
  • Information on the redesigned PS&R
  • Three NCDs and payment consequences for “wrong” surgeries
  • Posting of the FY 2010 ICD-9-CM
  • Revised MS LTC DRG weights
  • List of CMS transmittals to be implemented during the summer
  • And a Special Article on Version 5010 of the HIPAA Electronic Transaction Standards

• The May 2009 issue includes:
  • A summary of the proposed Inpatient PPS for FY 2010
  • The July I/OCE changes
  • A new patient status code for court/law enforcement
  • Recoupment of overpayments for MS-DRG 956
  • Claims for managed care clinical trial patients
  • July 2009 changes to the laboratory NCDs
  • And a special article “Incident-to Supervision of Outpatient Therapeutic Services: Are You in Compliance?”

• The April 2009 issue includes:
  • What to expect from the RACs as they begin their reviews
  • A summary of the ARRA provisions that affect teaching hospitals and long-term care hospitals
  • Coding and billing for clinical trials
  • Expanded coverage for use of PET scans with cancer patients
  • Medicare payment for maintenance and servicing of oxygen concentrators and certain other equipment
  • Clarified instruction for SNF billing of exhaust benefits
  • And a special article, “When Does CMS’ Anti-Markup Rule Apply?”

• The March 2009 issue includes:
  • A summary of the April updates to the Outpatient Prospective Payment System, the Integrated Outpatient Code Editor, and the ASC Payment System
  • The findings of an OIG audit of postacute care transfer billing…before and after CMS activated the edit to identify incorrect claims
  • Two coverage decisions affecting sleep apnea and bariatric surgery
  • Billing instructions for purchased diagnostic and lab tests performed by a provider outside the billing jurisdiction
  • Availability of a chart on billing noncovered charges and use of the new ABN
  • And a special article on the permanent RAC program

• The February 2009 issue includes:
  • A reminder of the required use of the new ABN that replaces ABN-G and ABN-L as of March 1
  • A summary of the billing and payment policies for co-surgeons at Method II critical access hospitals
  • Clarification of  the date of service for ambulance services when the beneficiary dies
  • The expected launch of the Long-Term Care Hospital Special Project
  • A CMS notice that reclassifies the drug code J3300 from an “N” to a “K” status
  • A new reporting requirement for drugs with FDA approval but without a specific drug code
  • New codes for inpatient telehealth consultations
  • CMS instructions to payers to review claims with modifier –79 and those for facet joint procedures
    Plus
  • A review of the criteria, documentation, and billing for observation services

• The January 2009 issue includes:
  • A summary of the January 2009 changes to the Outpatient Prospective Payment System and to the Integrated Outpatient Code Editor
  • News on continuation of the PEPPER program
  • HHS adoption of ICD-10 for HIPAA with a delay in the effective date
  • The results of the first round of the Hospital Outpatient Quality Data Reporting Program
  • The announcement of the final MACS
    Plus
  • A special article on the outlook for 2009 regarding program integrity efforts and high risk audit targets
• The December 2008 issue includes:
  • Revisions to the instructions for Form CMS-2552-96, Hospital and Health Care Complex Cost Report
  • Transmittal 418, which sets out the conditions for the exception to the three-year moratorium on new long-term care hospitals or increase in the number of LTCH beds
  • Updated list of CARCs and RARCs
  • New national coverage determinations
  • Furnishing fees for the clotting factor and the original site facility fee for telehealth services
  • Changes to the laboratory NCD edit module
  • Notice of collection of overpayments from home health agencies
    Plus
  • Article on recent revisions to Medical Records and Utilization Review Conditions of Participation and
  • The List of CMS Transmittals, effective in December 2008 and January 2009
• The November 2008 issue includes:
  • A summary of the 2009 Outpatient Prospective Payment System final rule
  • New J code for hemophilia patients with delayed submission
  • New ASC payment indicators
  • New C code for implanted prosthetic devices where patient has no Part A coverage
  • MIPPA revisions to the initial preventative physical examination
  • Clarification for billing assistants-at-surgery in a Method II CAH
  • Revised Medicaid definition of outpatient services
  • A MLN special edition article on how to transition from an FI/carrier to an A/B MAC
  • Plus a special article on IRF compliance with the Medicare transfer policy

• The October 2008 issue includes:
  • CMS Press Release Regarding Increased Fraud and Abuse Efforts
  • Announcement of the National RACs and Implementation Plans
  • Publication of the Medically Unlikely Edits
  • Summary of the October OPPS and ASC Updates
  • Release of OIG Supplemental Compliance Guidance for Nursing Facilities
  • Notice of Claims Hold for DRG 999 due to HAC logic problems
  • Transmittal Summarizing the Payment and Policy Changes for the IPPS and the IPF PPS
  • A Table of the FY 2009 Medicare Premiums, Co-Pays, and Deductibles
  • And a special article, “Hospitals, Contractors and Data Mining… What’s Next?”

• The September 2008 issue includes:
  • A summary of the I/OCE that becomes operational Oct. 6
  • Notice of an update to the Financial Management manual with the new Medicare process for recouping overpayments
  • Billing and claims processing information on the new NCD on artificial hearts
  • Notice of an extension of the hold on OPPS claims with code Q0091 (pap smear screening)
  • Results of a Trailblazer audit on problems reporting unlisted CPT codes
  • Quarterly table on CMS actions that will be implemented Oct. 6, 2008

• The August 2008 issue includes:
  • A summary of the final Inpatient Prospective Payment System rule for FY 2009
  • CMS’ announcement regarding adoption of ICD-10
  • A comparison of claims review processes used by different contractors
  • CMS’ explanation of the importance of correct completion of the Medicare cost reports
  • Announcement of the QIOs for the 9th Scope of Work
    
    
• The July 2008 issue includes summaries of:
  • the proposed Outpatient Prospective Payment System rule for 2009
  • the final report from CMS on the Recovery Audit Contractor pilot
  • the most recent CERT report
  • the OIG’s letter to providers regarding the impact of MIPPA on their liability
  • the CMS plan for medical review of inpatient claims now that the QIOs no longer carry that responsibility
  • and other transmittals relevant to billing compliance issued in July
    
    
• June 2008
• May 2008