All Entries in the "Coverage" Category
CMS Announces the 2010 Medicare Premiums and Deductibles
CMS recently announced the CY2010 Medicare Part A deductible for inpatient hospital services. When a patient is admitted as an inpatient, the deductible will increase from $1,068 in 2009 to $1,100 in 2010. In addition, beneficiaries will pay an additional daily coinsurance of $275 for days 61 through 90 and $550 for lifetime reserve days. For 2009, the corresponding amounts are $267 and $534, respectively.
The majority of Medicare beneficiaries do not have to pay a premium for Part A inpatient services. This is based on their previous Medicare-covered employment history or because they are a spouse or widow(er) of a covered beneficiary. However, a small percentage of beneficiaries will see an increase of $18 on their monthly premium to $451 per month for 2010. In some cases, beneficiaries will qualify to pay a reduced premium based on employment coverage and their monthly premium will be $254 in 2010.
CMS also announced that the Part B deductible will increase to $155 based on an annual percentage increase index. Unfortunately, the Social Security Administration also announced that there would be no increase in Social Security benefits for 2010. Medicare Part B monthly premiums cover a portion of the cost of outpatient hospital services, physicians’ services, certain home health services, durable medical equipment, and other items. In 2010, most Medicare beneficiaries (approximately 73%) will not see an increase in their monthly premiums as a result of a “hold harmless” provision in the current law. These beneficiaries will pay the same monthly premium that they paid in 2009 at $96.40. The other 27 percent of beneficiaries that are not protected by the hold-harmless provision because they are new Medicare enrollees during the year or because they are subject to premiums based on their income or other factors will pay the increased premium of $110.50. The Administration continues to urge Congress to take actions that would protect all beneficiaries from higher Part B premiums and eliminate the inequity between these two groups.
More detailed information can be found in the October 22 Federal Register and related fact sheet.
CMS clarifies RACs’ “exception authority”
On September 11, CMS published Transmittal 302 that updated the Program Integrity Manual on Local Coverage Determination (LCD) exceptions. When specific authorized contractors conduct a complex medical review, they have the authority (in rare and unusual circumstances) to apply an exception to the “reasonable and necessary” requirements described in an LCD to approve or deny a claim. However, they cannot make exceptions to National Coverage Determinations (NCDs). In addition, and unless otherwise directed by CMS, RACs can only use the exceptions process to not deny a claim. This is a good time to review the difference between a national and a local coverage determination policy.
NCDs are coverage policies created by CMS for an item or service to be applied on a national basis for all Medicare beneficiaries. NCDs help ensure that access to advances in technologies that may improve healthcare are available to Medicare beneficiaries when those items and services are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member”. However, NCDs may also be used to bar payment for specific items or services that are not “reasonable and necessary”.
LCDs are determinations made by a fiscal intermediary, carrier, or Medicare Administrative Contractor (MAC) in regards to whether or not a particular item or service is covered on an intermediary-, carrier-, or MAC-wide basis. LCDs specify the circumstances under which a service is generally considered to be “reasonable and necessary” to assist providers in submitting correct claims for payment. Medicare contractors develop LCDs when there is no NCD or when there is a need to further define an NCD. The contractors must make sure that all LCDs are consistent with all statutes, rulings, regulations, and national coverage, payment, and coding policies. In addition, codes describing what is covered and what is not covered can be part of the LCD; however, coding guidelines are not elements of LCDs.
It will be important for providers to understand where to locate and how to use an NCD and/or LCD during the RAC review and appeal processes. More information on draft, current and retired NCDs can be found in the MedicareFind database or on the CMS web site. CMS requires all draft, final (active), and retired LCD information to be posted to each contractor’s website.
CMS announces a coverage determination on the “screening virtual colonoscopy”
On August 7, CMS issued transmittal R105NCD to implement its decision to maintain non-coverage of computed tomography colonography (CTC) for colorectal cancer screening, also known as a “virtual colonoscopy.” In 2008, the medical community had recommended that CMS consider coverage of this exam for screening purposes in specific individuals. After performing its own review, CMS has determined that the current medical evidence is inadequate and that no national coverage determination (NCD) is appropriate at this time.
Currently, Medicare beneficiaries can receive one of the following colorectal cancer screening tests:
- Fecal occult blood test (guaiac-based or immunoassay-based) once every 12 months;
- Flexible sigmoidoscopy once every 4 years depending on risk factors;
- Screening colonoscopy once every 10 years for patients without a known risk;
- Screening colonoscopy once every 2 years for patients at high risk for colorectal cancer;
- Barium enema every 4 years as a substitute for a flexible sigmoidoscopy;
- Barium enema every 2 years as a substitute for a screening colonoscopy for high risk patients.
Since CMS has determined that screening CTCs are non-covered for dates of service on and after May 12, 2009, a signed ABN is not required to be able to bill the patient for the service. However, under the revised ABN instructions, it can be used to inform the patient in advance of their financial responsibility.
More information on covered colorectal cancer screening services can be found in the Medicare Claims Processing Manual, Chapter 18, and the Medicare Benefit Policy Manual, Chapter 1.
Never Events—CMS issues surgical error NCDs and related guidance
In 2002, the National Quality Forum (NQF) published a list of 27 events identified as “serious, largely preventable and of concern to both the public and health care providers.” These events have become more popularly known as “never events”—events that should never occur in a well-run health care facility with appropriate quality controls. The updated list currently contains 28 adverse events, including the following surgical errors:
- Wrong surgical or other invasive procedure performed on a patient;
- Surgical or other invasive procedure performed on the wrong body part; and
- Surgical or other invasive procedure performed on the wrong patient.
New modifiers for outpatient never events; billing for hospital-acquired conditions
This week, CMS published the July Integrated Outpatient Code Editor (I/OCE). Although there were relatively few changes, CMS did introduce three new modifiers for use with the occurrence of three never events identified by the National Quality Forum (NQF) that were recently the subject of National Coverage Analyses by CMS. The new modifiers are: PA for surgical or invasive procedure on the wrong body part, PB for surgical or invasive procedure on the wrong patient, and PC for wrong surgery or invasive procedure on patient. The modifiers were added to the list of valid modifiers effective January 1, 2009.
Compliance with Condition Code 44 – A practical approach
This week, let’s continue our focus on the so-called Condition Code 44 process. If followed carefully, this process would permit hospitals to convert what would otherwise be non-covered inpatient services under Part A to outpatient services under Part B. Once converted, presumably, these services would then be subject to the same terms and conditions of coverage as if they actually had been provided in the outpatient setting. [more]
Condition Code 44 – Let’s focus on process
Last week, Kimberly Hoy brought up some additional questions about the conversion of inpatient hours to observation time, following a Condition Code 44 change of inpatient status to outpatient care. That article prompted several additional questions from readers, including questions about the process that hospitals need to follow in order to assure that they receive essentially the same reimbursement for those inpatient services as they would have received if the services actually had been provided in the outpatient setting. [more]
Observation with condition code 44 and physician supervision
Last week, the American Health Lawyers Association held their annual Institute on Medicare and Medicaid Payment Issues in Baltimore. After speaking about observation at a conference session, I had the opportunity to speak to a CMS representative informally about condition code 44 as it relates to observation and also about physician supervision in hospital outpatient departments. [more]
Listen to the February 25 Hospital Open Door Forum
CMS held its latest conference call for hospitals on February 25. This call featured an extensive discussion of “incident to.” If you’re new to this issue, check out the discussion here.
You can listen to the audio below. Subscribers to the MedicareFind database also have access to a transcript of the call.
What is your reaction to CMS’ recent activity regarding “incident to” coverage requirements?
Try a free trial to MedicareFind and gain access to transcripts and audio of CMS’ Hospital Open Door Forum calls.
Application of critical care Correct Coding Initiative (CCI) edits to hospitals
Effective January 1, 2009, the CCI edits for evaluation and management (E&M), including critical care, apply to hospitals. Two prior-existing frequently asked questions (FAQ) have been updated to reflect these changes. The updated FAQs are FAQ 8813 and FAQ 2392. Prior to January 1, 2009, not all CCI edits that applied to physician services also applied to comparable hospital services. In particular, those CCI edits that applied to physician E&M services (including critical care) were not incorporated into the Outpatient Code Editor (OCE) for application to hospital E&M services. [more]
