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Regulatory MonitoringArchive for December, 2008
By Kimberly Anderwood Hoy, director of Medicare and compliance for HCPro
This week, CMS published the laboratory Medicare National Coverage Determinations Coding Policy Manual and Change Report, containing medical necessity edits for 23 common diagnostic laboratory tests. CMS published a transmittal earlier in December announcing these changes, and the policies also appear in the Internet-only Medicare National Coverage Determinations Manual (NCD Manual). However, the best reference is the Policy Manual and Change Report.
The Policy Manual and Change Report contains several additional sections not available in the NCD Manual. There is a section containing codes that are never covered for laboratory tests because they represent non-covered screening reasons for laboratory tests. When these diagnosis codes are the reason for performing a laboratory test, CMS has clarified that no Advanced Beneficiary Notice of Noncoverage is necessary to hold the patient responsible for the test. There are also general coding instructions and coding instructions for each edit, which are not included in the policies for the individual tests and only appear in the Policy Manual and Change Report.
The Policy Manual and Change Report typically appears on its own Web site. You can access the January 2009 version at www.cms.hhs.gov/CoverageGenInfo/Downloads/manual200901.pdf. Prior versions of the manual are available at www.cms.hhs.gov/CoverageGenInfo/04_LabNCDs.asp.
CMS grants waivers from requirements under Clinical Laboratory Improvement Amendments of 1988 (CLIA)
On December 22, CMS published in the Federal Register a notice announcing it has granted exemptions from CLIA requirements to certain laboratories in New York state.
CMS implements no changes to NCD for percutaneous transluminal angioplasty (PTA) of the carotid artery concurrent with stenting
On December 24, CMS issued a transmittal maintaining its current NCD for PTA of the carotid artery concurrent with stenting. The NCD continues to provide coverage for certain patient populations under specific conditions.
Effective date: October 14, 2008
Implementation date: January 26, 2009
CMS updates hospital cost report form and instructions
On December 24, CMS issued a transmittal updating the “Hospital and Hospital Health Care Complex Cost Report.” The effective dates for instructional changes vary.
CMS updates NCD manual for clinical diagnostic laboratory services
CMS has released its January 2009 update to the NCD manual for clinical diagnostic laboratory services.
OIG issues reports comparing average sales prices (ASP) to average manufacturer prices (AMP) for prescription drugs
The OIG released two reports comparing ASPs to AMPs for drugs reimbursed under Medicare Part B’s ASP-based methodology.
View the report on ASP vs. AMP for 2007.
View the report on ASP vs. AMP for first quarter, 2008.
OIG issues reports on high-dollar payments for inpatient and outpatient services processed by First Coast Service Options, Inc., for the period January 1, 2004 through December 31, 2005
The OIG released two reports on high-dollar payments for inpatient services and outpatient services processed by First Coast, a Medicare fiscal intermediary, for the period January 1, 2004 through December 31, 2005.
View the OIG report on inpatient high-dollar claims processed by First Coast.
View the OIG report on outpatient high-dollar claims processed by First Coast.
Frequently asked question
On December 22, CMS updated a frequently asked question regarding recent changes to the definitions of new and established patients under the OPPS.
How is the new or established patient classification determined under the Outpatient Prospective Payment System (OPPS)? For example, is a clinic patient considered new or established if he was treated in an off-site clinic of the hospital or the hospital’s emergency department within the past 3 years? (View answer.)
OIG issues adverse events case study
On December 19, the OIG issued a case study on the incidence of adverse events among Medicare beneficiaries in two select counties.
In light of the significant number of changes to the revised ABN (including the related revisions to Chapter 30, Section 50 of the Medicare Claims Processing Manual) and the potential consequences for failure to provide advance notification when limitation on liability applies, healthcare providers are encouraged to do the following:
- Form a cross-disciplinary team with related responsibilities to transition to the revised ABN
- Review the revised ABN form
- Review the ABN FAQs and Form Instructions, as well as the revised provisions in Chapter 30, Section 50 in the Medicare Claims Processing Manual
- Review the existing Forms ABN-G and ABN-L, as well as the current ABN notification process
- Identify any outstanding questions that require clarification before proceeding
- Identify key changes that need to be implemented in order to be able to transition to the revised ABN by March 1, 2009
- Create a transition action plan, with timetables and accountability by departments/key individuals
- Implement the action plan, with ongoing monitoring and evaluation to determine whether target dates and plan objectives are being met
Editor’s note: Judith L. Kares, JD, CPC, authored this submission. She is an instructor for HCPro’s Medicare Boot Camp – Hospital Version. She is a lawyer and consultant who provides legal services and related healthcare compliance services to a wide variety of clients, including hospitals, health systems, HMOs, third party payers, physician practices and other healthcare entities. Visit www.hcprobootcamps.com to learn more.
A federal judge sentenced a former assistant vice president at Wachovia Bank to three years in prison for submitting fraudulent claims to Medicare, bizjournals.com reported this week.
Prosecutors said Javier J. Ortiz, 36, opened accounts for medical companies owned by Angel Castillo Jr.
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