Training Programs
Audits & Assessments
Regulatory MonitoringArchive for e-Newsletters
The stimulus plan passed by the Senate Tuesday includes millions of dollars for Medicaid, meaning hospitals may see a lift in reimbursements.
The Senate voted to approve an $838 billion economic stimulus plan after the House passed a $820 billion version earlier, The New York Times reported.
“Throughout our history, the federal government has catalyzed a good idea, invested in the ingenuity and entrepreneurship of the American people, and let the private sector flourish,” the majority leader, Senator Harry Reid of Nevada, said before the vote, The New York Times reported. “Faced with an economic crisis today, we have an opportunity to make similar investments that will help our country prosper in the years to come.”
Read the full story in The New York Times.
CMS instructs contractors to strengthen program safeguards for facet joint injection services
On February 6, CMS issued a transmittal instructing its contractors to strengthen safeguards against improper payment of claims for facet joint injection services. The instructions follow an OIG audit finding that 63% of facet joint injection services allowed in 2006 did not meet Medicare program requirements.
Effective date: March 9, 2009
Implementation date: March 9, 2009
CMS announces change to amount in controversy requirement for administrative law judge (ALJ) hearings and Federal District Court appeals
On January 30, CMS issued a transmittal notifying its contractors of a change to the amount in controversy requirement for ALJ hearings and appeals in Federal District Court.
Effective date: March 4, 2009
Implementation date: March 4, 2009
View a related MLN Matters article.
CMS issues transmittal on payment for co-surgeons in a method II critical access hospital (CAH)
On January 30, CMS released a transmittal to implement several changes to the way contractors issue payment for co-surgeons when a CAH is involved.
Effective date: January 1, 2008
Implementation date: July 6, 2009
View a related MLN Matters article.
MLN Matters articles
CMS released the following MLN Matters article related to an item previously covered in Medicare Weekly Update.
CMS also released the following special edition MLN Matters article.
CMS clarifies policy on CLIA certificates for entities with multiple sites
On February 6, CMS issued a clarification of its policies and procedures for entities with one CLIA certificate for multiple sites.
OIG issues reports on oxaliplatin billing
On February 2, the OIG released a report on oxaliplatin billing at San Angelo Community Medical Center. The OIG found that San Angelo received overpayments totaling $233,000 in 2004. On February 6, the OIG issued a report on oxaliplatin billing at Lovelace Medical Genter – Gibson. The OIG found that Lovelace received overpayments totaling $128,000 in 2004.
View the OIG report regarding San Angelo Community Medical Center.
View the OIG report regarding Lovelace Medical Center – Gibson.
OIG issues review of high-dollar payments for Medicare outpatient claims processed by TriSpan Health Services for the period January 1 through December 31, 2005
On February 2, the OIG issued a report on high-dollar outpatient claims processed by TriSpan Health Services. The OIG determined that TriSpan overpaid providers $782,000 in 2005.
By Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc.
SIs “N,” “Q1,” Q2,” and “Q3”
In CY 2008, CMS greatly expanded the number of packaged items and services payable under the Outpatient Prospective Payment System (OPPS). More than 300 items and services that had formerly been separately payable became packaged, at least in certain circumstances. CMS is continuing this trend in CY 2009. Presently, there are four status indicators (SI) that identify packaged items and services: “N,” “Q1,” “Q2,” and “Q3.” Addendum D1 to the CY 2009 OPPS final rule defines SI “N” as identifying items and services that are paid under the OPPS; however, there is no separate payment for them. Instead, payment is included in the payment for other items and services. Think of those services as “never” being separately payable.
There are a number of other items and services that are “sometimes packaged” and “sometimes separately payable.” In 2008, all of the “sometimes packaged” items and services were identified with the “Q” SI. These “Q” SI codes were then further divided into three subcategories, which established the criteria for determining whether they would be packaged or separately payable in particular circumstances. Those three subcategories were as follows:
- “STVX-packaged codes”;
- “T-packaged codes”; and
- Codes subject to payment as part of a composite.
In the CY 2009 final rule, CMS assigned separate SIs to each subcategory:
- “STVX-packaged codes”—“Q1”;
- “T-packaged codes”—“Q2”; and
- Codes subject to payment as part of a composite—“Q3.”
“STVX-packaged codes” (SI “Q1”) are packaged if they are billed on the same date of service with any other code with an SI of “S,” “T,” “V,” or “X.” If not, they are separately payable under a separate APC. “T-packaged codes” (SI “Q2”) are packaged only if they are billed on the same date of service with any other codes with an SI of “T.” If not, they are separately payable under a separate APC. Codes subject to payment as part of a composite (SI “Q3”) are packaged into the composite rate when all criteria for that composite are met. Otherwise, the services with SI “Q3” may be separately payable if otherwise assigned to a separate APC or packaged into other services, if not.
If more than one “STVX-packaged” (“Q1”) or “T-packaged” (“Q2”) code is reported without a separately payable service into which it would otherwise be packaged, separate payment is made only for the highest paying among them, and all others are packaged into that code. If any SI “Q1” or “Q2” codes are reported on the same day as any code that is subject to composite payment (“Q3”), and payment criteria are met for composite payment, the “Q1” and ”Q2” codes will be packaged into the composite payment.
If separately payable, codes with SIs “Q1,” “Q2,” and “Q3” are subject to wage index adjustment. In addition, the wage index adjustment will be applied to either the national payment rate calculated using the full market basket conversion factor or the national payment rate calculated using the reduced market basket conversion factor. Only those hospitals who met their outpatient quality reporting requirements for CY 2008 will be eligible for the full market basket update.
SIs “R” and “U”
There were two additional SI changes implemented in CY 2009: SIs “R” and “U.” SI “R” applies to blood and blood products. This SI was added to distinguish blood and blood products from other biologicals that are neither subject to wage index adjustment nor subject to adjustment to the national payment rate if the hospital fails to meet its outpatient quality indicator reporting requirements. Blood and blood products are subject to both adjustments, if applicable.
The last change was assignment of SI “U” to brachytherapy seeds and sources. Medicare has been attempting to assign APC-based payments to these services over the last few years. Repeatedly, however, CMS has continued to reimburse them based on charges reduced to cost. Most recently, Congress enacted legislation to extend payment based on charges reduced to cost through the end of CY 2009. Prior to CY 2009, because they were reimbursed based on cost, brachytherapy seeds and sources were assigned SI “H.” CMS changed their SI to “U,” beginning with services provided on and after 1/1/09, regardless of the payment methodology. Unlike blood and blood products, brachytherapy seeds and sources are not subject to wage index adjustment nor are they subject to the reduced update, in the event that the hospital fails to meets its outpatient quality indicator reporting requirements.
It does not pay enough money.
That is the contention of Wellcare, Florida’s largest Medicaid insurer, which announced it is leaving the state’s Medicaid Reform program, The Miami Herald reported this week. Government reimbursement rates are just too low, the insurer said.
”WellCare’s action is a result of recent state budget cuts that make it economically unfeasible to continue offering members sufficient access to quality health services in those programs,” the company said in a written statement.
”It’s fair to say that the rate cuts are substantial enough that some plans will soon have to decide whether to stay,” said Michael Garner, president of the Florida Association of Health Plans, in The Herald.
A consumer group aims to monitor quality of Medicare billing and get rid of waste. But an appeals court won’t let them for now, the Associated Press reports.
A federal appeals court on January 30 overturned the decision to allow the nonprofit Consumers’ Checkbook access to medical billing records under the federal Freedom of Information Act. HHS and the AMA appealed the initial 2007 ruling, and a three-judge panel, in a split decision, reversed the decision.
“The requested data does not serve any (freedom-of-information-related) public interest in disclosure,” Circuit Judge Karen LeCraft Henderson wrote for the majority, the Associated Press reports. “Accordingly, we need not balance the nonexistent public interest against every physician’s substantial privacy interest in the Medicare payments he receives.”
“The majority opinion seems to misunderstand how these data would be used,” Robert Krughoff, president of the consumer group, told the Associated Press. “It doesn’t accurately portray how the data can be used to monitor the quality of healthcare provided under the Medicare program.”
By Kimberly Anderwood Hoy, director of Medicare and compliance for HCPro, Inc.
As many of you know, CMS maintains two sets of NCCI edits: one for hospitals and one for physicians. The hospital version of the edits is one quarter behind the physician version. This can cause significant compliance issues for hospitals.
Read More→
Get blog updates in your e-mail
Subscribe to our free RAC Report e-zine
