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1 NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement. Read the copyright statement now and you will be linked back to here.

2 JM HHH Medicare Advisory What s Inside... Latest Medicare News for JM Home Health & Hospice CMS e-news...2 Medicare Finalizes Substantial Improvements that Focus on Primary Care, Mental Health, and Diabetes Prevention Payment Rules CMS Finalizes Hospital OPPS Changes to Better Support Hospitals and Physicians and Improve Patient Care...4 Home Health Agencies: Final Payment Changes...5 ESRD PPS: Policies and Payment Rates for End-Stage Renal Disease...6 Home Health and Hospice Information...7 Therapy Cap Values for Calendar Year (CY) New Physician Specialty Code for Hospitalist...8 Modifications to the National Coordination of Benefits Agreement Crossover Process...9 January 2017 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files Annual Update to the Therapy Code List...12 Correcting Editing for Condition Code 54 and Updating Remittance Advice Messages on Home Health Claims...14 Denial of Home Health Payments When Required Patient Assessment Is Not Received...15 Implementation of Policy Changes for the CY 2017 Home Health Prospective Payment System...16 Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) Comprehensive Care for Joint Replacement Model (CJR) Provider Education...27 eservices Makes Asking a Medicare Question Easier!...33 Managing Multiple eservice Accounts Just Got Easier with Account Linking!...34 Get Your Medicare News Electronically...34 Medicare Learning Network (MLN)...35 CallBack Assist...36 Learning and Education Information...36 Quarterly Updates, Changes, and Reminders Webcast December 15, Home Health Pre-Claim Review Documentation Requirements Workshops...37 December 2016 Volume 2016, Issue 12 palmettogba.com/hhh The JM HHH Medicare Advisory contains coverage, billing and other information for Jurisdiction M HHH. This information is not intended to constitute legal advice. It is our official notice to those we serve concerning their responsibilities and obligations as mandated by Medicare regulations and guidelines. This information is readily available at no cost on the Palmetto GBA website. It is the responsibility of each facility to obtain this information and to follow the guidelines. The JM HHH Medicare Advisory includes information provided by the Centers for Medicare & Medicaid Services (CMS) and is current at the time of publication. The information is subject to change at any time. This bulletin should be shared with all health care practitioners and managerial members of the provider staff. Bulletins are available at no-cost from our website at CPT only copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright 2012 American Dental Association (ADA). All rights reserved.

3 Medical Policy Information...39 HHH Local Coverage Determinations (LCDs) Updates...39 Tools You Can Use...41 Medicare Credit Balance Report Module...41 Helpful Information...43 Contact Information for Palmetto GBA Home Health and Hospice...43 December 2016 Home Health and Hopspice Education Events December 15, 2016, Quarterly Updates, Changes, and Reminders Webcast Palmetto GBA will host the Home Health and Hospice Quarterly Updates Webcast on Thursday, December 15, 2016, at 10 a.m. ET. Home Health Pre-Claim Review Documentation Requirements Workshops Palmetto GBA is pleased to announce the Home Health Pre-Claim Review Documentation Requirements workshop series. This is the second round of PCR workshops for the demonstration states. For more information and registration instructions for these events, please go to the Learning and Education section begining on Page 36 of this issue. CMS E-NEWS CMS e-news will contain a week s worth of Medicare-related messages from the Centers of Medicare & Medicaid Services (CMS). These messages ensure planned, coordinated messages are delivered timely about Medicare-related topics. Please share with appropriate staff. To view the most recently issues, please copy and paste the following links into your Web browser: November 17, pdf November 10, pdf November 3, pdf 2 12/2016

4 Medicare Finalizes Substantial Improvements that Focus on Primary Care, Mental Health, and Diabetes Prevention On November 2, CMS finalized the 2017 Physician Fee Schedule final rule that recognizes the importance of primary care by improving payment for chronic care management and behavioral health. The rule also finalizes many of the policies to expand the Diabetes Prevention Program model test to eligible Medicare beneficiaries, the Medicare Diabetes Prevention Program (MDPP) expanded model, starting January 1, The annual Physician Fee Schedule updates payment policies, payment rates, and quality provisions for services provided in CY In addition to physicians, a variety of practitioners and entities are paid under the physician fee schedule. Additional policies finalized in the 2017 payment rule include: Primary care and care coordination Mental and behavioral health Cognitive impairment care assessment and planning The 2017 payment rule will also: Finalize a data collection strategy for global services with significantly reduced burden for practitioners compared to the proposal Finalize a change that will more accurately reflect local costs and significantly increase payments to practitioners in Puerto Rico Enhance program integrity and data transparency in the Medicare Advantage program. For More Information: Final Rule ( PFS Fact Sheet ( MDPP Fact Sheet ( Blog ( ) 3 12/2016

5 See full text of this excerpted CMS press release ( MediaReleaseDatabase/Press-releases/2016-Press-releases-items/ html?dlpage=1&dlentries=10&dlsort=0&dlsortdir=descending) (issued November 2) 3 Payment Rules CMS Finalizes Hospital OPPS Changes to Better Support Hospitals and Physicians and Improve Patient Care On November 1, CMS finalized updated payment rates and policy changes in the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System for CY CMS is also adding new quality measures to the Hospital Outpatient Quality Reporting Program and the ASC Quality Reporting Program that are focused on improving patient outcomes and experience of care. CMS estimates that the updates in the final rule would increase OPPS payments by 1.7 percent and ASC rates by 1.9 percent in Included in the rule: Addressing physicians concerns regarding pain management Focusing payments on patients rather than setting Improving patient care through technology For More Information: Final Rule ( Fact Sheet ( See the full text of this excerpted CMS Press Release ( MediaReleaseDatabase/Press-releases/2016-Press-releases-items/ html) (issued November 1). 4 12/2016

6 Home Health Agencies: Final Payment Changes On October 31, CMS announced final changes to the Medicare Home Health (HH) Prospective Payment System (PPS) for CY In the final rule (CMS-1648-F), CMS estimates that Medicare payments to home health agencies in CY 2017 would be reduced by 0.7 percent, or $130 million based on the finalized policies. Payment policy provisions: Rebasing the 60-day episode rate Updates to reflect case-mix growth Negative Pressure Wound Therapy Change in methodology and the fixed-dollar loss ratio used to calculate outlier payments Other updates The final rule also includes: Home Health Quality Reporting Program Home Health Value-Based Purchasing Model For More Information: Final Rule ( HH PPS website ( HH Value-Based Purchasing Model webpage ( See the full text of this excerpted CMS fact sheet ( Fact-sheets/2016-Fact-sheets-items/ html) (issued October 31). 5 12/2016

7 ESRD PPS: Policies and Payment Rates for End-Stage Renal Disease On October 28, CMS issued a final rule (CMS 1651-F) that updates payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, This rule also: Finalizes new quality measures to improve the quality of care by dialysis facilities treating patients with ESRD Implements the Trade Preferences Extension Act of 2015 provisions regarding the coverage and payment of renal dialysis services furnished by ESRD facilities to individuals with acute kidney injury Makes changes to the ESRD Quality Incentive Program (QIP), including Payment Years (PYs) 2019 and 2020 Makes changes to the scoring methodology for the ESRD QIP for PY 2019 and added one new measure Addresses issues related to Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and the DMEPOS Competitive Bidding Program The finalized CY 2017 ESRD PPS base rate is $ CMS projects that the updates for CY 2017 will increase the total payments to all ESRD facilities by 0.73 percent compared with CY For hospitalbased ESRD facilities, CMS projects an increase in total payments of 0.9 percent, while for freestanding facilities, the projected increase in total payments is 0.7 percent. Aggregate ESRD PPS expenditures are projected to increase by approximately $80 million from CY 2016 to CY Changes to the ESRD PPS: Update to the base rate Annual update to the wage index and wage index floor Update to the outlier policy Home and self-dialysis training add-on payment adjustment Changes to the DMEPOS Competitive Bidding Program: Bid surety bond State licensure Appeals process for breach of contract actions Bid limits Changes for similar items with different features 6 12/2016

8 For More Information: Final Rule ( See the full text of this excerpted CMS fact sheet ( (issued October 28). HOME HEALTH AND HOSPICE INFORMATION Therapy Cap Values for Calendar Year (CY) 2017 MLN Matters Number: MM9865 Related Change Request (CR) #: CR 9865 Related CR Release Date: November 4, 2016 Effective Date: January 1, 2017 Related CR Transmittal #: R3644CP Implementation Date: January 3, 2017 Provider Types Affected This MLN Matters Article is intended for physicians, therapists, and other providers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare beneficiaries. Provider Action Needed Change Request (CR) 9865, from which this article was developed, describes the amounts and policies for outpatient therapy caps for CY For physical therapy and speech-language pathology combined, the 2017 therapy cap will be $1,980. For occupational therapy, the cap for 2017 will be $1,980. Make sure that your billing staffs are aware of these therapy cap value updates. 7 12/2016

9 Background The Balanced Budget Act of 1997 (P.L ), Section 4541(c) applies annual financial limitations on expenses considered incurred for outpatient therapy services under Medicare Part B per beneficiary, commonly referred to as therapy caps. Therapy caps are updated each year based on the Medicare Economic Index. An exception for the therapy caps for reasonable and medically necessary services has been in place since CY Originally required by Section 5107 of the Deficit Reduction Act of 2005, the exceptions process for the therapy caps has been continuously extended multiple times through subsequent legislation. The current therapy caps exceptions process, as required by Section 202 of the Medicare Access and CHIP Reauthorization Act of 2015, expires on December 31, CR 9865 establishes that therapy caps for CY 2017 will be $1,980. MACs will update to this amount for physical therapy and speech-language pathology combined, and for occupational therapy. Additional Information The official instruction, CR9865, issued to your MAC regarding this change is available at cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r3644cp.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. New Physician Specialty Code for Hospitalist MLN Matters Number: MM 9716 Related Change Request (CR) #: CR 9716 Related CR Release Date: October 28, 2016 Effective Date: April 1, 2017 Related CR Transmittal #: R3637CP and R274FM Implementation Date: April 3, 2017 Provider Types Affected This MLN Matters Article is intended for physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries. Provider Action Needed Change Request (CR) 9716 announces that the Centers for Medicare & Medicaid Services (CMS) has established a new physician specialty code for Hospitalist. The new code for Hospitalist is C6. Make sure your billing staffs are aware of this physician specialty code. 8 12/2016

10 Background When they enroll in the Medicare program, physicians self-designate their Medicare physician specialty on the Medicare enrollment application (CMS-855I or CMS-855O), or in the Internet-based Provider Enrollment, Chain and Ownership System (PECOS). CMS uses these Medicare physician specialty codes, which describe the specific/unique types of medicine that physicians (and certain other suppliers) practice, for programmatic and claims processing purposes. Medicare will also recognize the new code of C6 as a valid specialty for the following edits: Ordering/certifying Part B clinical laboratory and imaging, durable medical equipment (DME), and Part A home health agency (HHA) claims Critical Access Hospital (CAH) Method II Attending and Rendering claims Attending, operating, or other physician or non-physician practitioner listed on CAH claims Additional Information The official instruction, CR9716, issued to your MAC regarding this change consists of two transmittals. The first updates the Medicare Claims Processing Manual and it is available at Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3637CP.pdf. The second updates the Medicare /Financial Management Manual at Guidance/Transmittals/Downloads/R274FM.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. Modifications to the National Coordination of Benefits Agreement Crossover Process MLN Matters Number: MM9681 Related Change Request (CR) #: CR 9681 Related CR Release Date: October 27, 2016 Effective Date: April 1, 2017 Related CR Transmittal #: R1733OTN Implementation Date: April 3, 2017 Provider Types Affected This MLN Matters Article is intended for providers, including hospices, submitting institutional claims to Medicare Administrative Contractors (MACs) requiring Coordination of Benefits (COB) for services provided to Medicare beneficiaries. 9 12/2016

11 Provider Action Needed Change Request (CR) 9681 modifies Medicare s Part A claims processing system to, among other things: Always ensure that a Remittance Advice Remark Code (RARC) accompanies claim denials tied to Claims Adjustment Reason Code (CARC) 16, as required. Prevent duplicate entry of hospital day counts expressed as value codes (for example, value code 80, 81, 82). Prevent reporting of Present on Admission (POA) indicators on outpatient Coordination of Benefits (COB) facility claims. Make sure your billing staff is aware of these changes. Background The Council for Affordable Quality Healthcare Committee for Operating Rules for Information Exchange (CAQH CORE) dictates which CARC and RARC combinations must be used by all covered entities in the healthcare industry. Medicare routinely reports CARCs and RARCs on Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Institute (ASC) 835 Electronic Remittance Advice (ERA) transactions in accordance with HIPAA requirements. Medicare also includes CARCs and RARCs within HIPAA ASC 837-N claims transactions, including 837 Coordination of Benefits (COB) claims transactions. However, within 837 claims transactions, RARCs are referred to as Claim Payment Reason Codes and appear within the 2320 Medicare Inpatient Adjudication Information (MIA) and Medicare Outpatient Adjudication Information (MOA) segments. As a result of systems issues, MACs are not always including a valid and relevant RARC in the 2320 MIA field when they deny Medicare claims. Medicare crossover claims are often being rejected by supplemental payers as a consequence. Though not the only example, this scenario seems to occur frequently when a claim service line is editing to deny with CARC code 16 Claim lacks information or has submission/ billing error(s) which is needed for adjudication... CR9681 will ensure that at least one informational RARC is provided to comply with HIPAA and CAHQ/CORE requirements. The Part A system is producing instances of duplicated hospital day counts on outbound 837 institutional COB/crossover claims. CR9681 remedies this situation. Important: Hospital billing staffs should avoid entering hospital day counts via Direct Data Entry (DDE) screens. Lastly, at present there is no editing with the Part A system to prevent the entry of a POA indicator on incoming outpatient facility claims. CR9681 remedies this issue by returning to the provider (RTP) any outpatient claim (type of bill other than 11x, 18x, 21x, 41x, and 82x) that contains a POA indicator. Important: Billing vendors for hospitals should make it a practice to only include POA indicators on 11x, 18x, 21x, 41x, and 82x type of bill (TOB) claims submitted to Medicare. Additional Information The official instruction, CR9681, issued to your MAC regarding this change is available at cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r1733otn.pdf /2016

12 If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. January 2017 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files MLN Matters Number: MM9843 Related Change Request (CR) #: CR 9843 Related CR Release Date: October 28, 2016 Effective Date: January 1, 2017 Related CR Transmittal #: R3640CP Implementation Date: January 3, 2017 Provider Types Affected This MLN Matters Article is intended for physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. What You Need to Know Change Request (CR) 9843 provides the January 2017 quarterly update and instructs MACs to download and implement the January 2017 ASP drug pricing files and, if released by the Centers for Medicare & Medicaid Services (CMS), the revised October 2016, July 2016, April 2016, and the January 2016 Average Sales Price (ASP) drug pricing files for Medicare Part B drugs. Medicare will use these files to determine the payment limit for claims for separately payable Medicare Part B drugs processed or reprocessed on or after January 3, 2017 with dates of service January 1, 2017, through March 31, MACs will not search and adjust claims previously processed unless brought to their attention. Make sure your billing staffs are aware of these changes. Background The ASP methodology is based on quarterly data submitted to CMS by manufacturers. CMS will supply MACs with the ASP and Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through separate instructions that are in Chapter 4, Section 50 of the Medicare Claims Processing Manual at Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. The following table shows how the quarterly payment files will be applied Files Effective Dates of Service January 2017 ASP and ASP NOC January 1, 2017, through March 31, 2017 October 2016 ASP and ASP NOC October 1, 2016, through December 31, /2016

13 July 2016 ASP and ASP NOC July 1, 2016, through September 30, 2016 April 2016 ASP and ASP NOC April 1, 2016, through June 30, 2016 January 2016 ASP and ASP NOC January 1, 2016, through March 31, 2016 Additional Information The official instruction, CR9843, issued to your MAC regarding this change is available at cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r3640cp.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/ Annual Update to the Therapy Code List MLN Matters Number: MM9782 Related Change Request (CR) #: CR 9782 Related CR Release Date: November 10, 2016 Effective Date: January 1, 2017 Related CR Transmittal #: R3654CP Implementation: January 3, 2017 Provider Types Affected This MLN Matters Article is intended for physicians, therapists, and other providers, including Comprehensive Outpatient Rehabilitation Facilities (CORFs), submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare beneficiaries. What You Need to Know This article is based on Change Request (CR) 9782 which updates the therapy code list for Calendar Year (CY) 2017 by adding eight always therapy codes ( ) for physical therapy (PT) and occupational therapy (OT) evaluative procedures. CR 9782 also deletes the four codes currently used to report these services ( ). Make sure your billing staffs are aware of these updates. Background Section 1834(k)(5) of the Social Security Act requires that all claims for outpatient rehabilitation therapy services and CORF services be reported using the uniform coding system. The Calendar Year (CY) 2017 Healthcare Common Procedure Coding System and Current Procedural Terminology, Fourth Edition (HCPCS/CPT-4) is the coding system used for reporting these services. For CY 2017, the Current Procedural Terminology (CPT) Editorial Panel created eight new codes ( ) to replace the 4-code set ( ) for Physical Therapy (PT) and Occupational Therapy (OT) evaluative procedures. The new CPT code descriptors for PT and OT evaluative procedures include specific components that are required for reporting as well as the corresponding typical face-to-face times for each service /2016

14 Evaluation Codes. The CPT Editorial Panel created three new codes to replace each existing PT and OT evaluation code, and 97003, respectively. These new evaluation codes are based on patient complexity and the level of clinical decision-making low, moderate and high complexity: for PT, codes 97161, and 97163; and for OT, codes 97165, and Re-evaluation Codes. One new PT code, 97164, and one new OT code, 97168, were created to replace the existing codes and 97004, respectively. The re-evaluation codes are reported for an established patient s when a revised plan of care is indicated. Just as their predecessor codes were, the new codes are always therapy and must be reported with the appropriate therapy modifier, GP or GO, to indicate that the services are furnished under a PT or OT plan of care, respectively. The new PT Evaluative procedure codes are listed in the chart below with their short descriptors* and the required corresponding therapy modifier: CPT Code Short Descriptor* Modifier PT EVAL LOW COMPLEX 20 MIN GP PT EVAL MOD COMPLEX 30 MIN GP PT EVAL HIGH COMPLEX 45 MIN GP PT RE-EVAL EST PLAN CARE GP The new OT Evaluative procedure codes are listed in the chart below with their short descriptors* and the required OT therapy modifier: CPT Code Short Descriptor* Modifier OT EVAL LOW COMPLEX 30 MIN GO OT EVAL MOD COMPLEX 45 MIN GO OT EVAL HIGH COMPLEX 60 MIN GO OT RE-EVAL EST PLAN CARE GO *NOTE: Please note that the short descriptors cannot be used in place of the CPT long descriptions which officially define each new PT and OT service. Refer to the two tables with these new CPT codes and their long descriptions that appear at the end of this article. Additional Information The official instruction, CR9782, issued to your MAC regarding this change is available at cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r3654cp.pdf. The therapy code list of always and sometimes therapy services is available at Medicare/Billing/TherapyServices/index.html /2016

15 If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. Correcting Editing for Condition Code 54 and Updating Remittance Advice Messages on Home Health Claims MLN Matters Number: MM9826 Related Change Request (CR) #: CR 9826 Related CR Release Date: October 27, 2016 Effective Date: Claims received on or after April 1, 2017 Related CR Transmittal #: R3630CP Implementation Date: April 3, 2017 Provider Types Affected This MLN Matters Article is intended for physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. What You Need to Know Change Request (CR) 9826 informs MACs about corrections to Medicare systems to require condition code 54 on Home Health (HH) appropriately. The system edit that enforces proper reporting of condition code 54 should only set when no skilled visits are reported by the provider. Currently, the edit is also setting when skilled service lines are denied during review. CR9826 also updates remittance advice coding combinations to ensure compliance with industry standards. CR9826 contains no new policy. Background CR9474 updated Original Medicare systems to accept and process condition code 54 in cases when a HH claim contained no skilled visits in a billing period and a policy exception is documented at the Home Health Agency (HHA). A system edit requires condition code 54 to be present when a claim for an episode of continuing care is submitted for payment with no skilled visits. This edit is functioning properly with regard to visits submitted as non-covered by the HHA. Shortly after CR9474 was implemented, MACs reported that the edit is also setting on claims that were submitted with covered skilled visits but those visits were non-covered during medical review. CR9826 corrects this problem. As a result of CR9826, Medicare will return claims to the HHA when the type of bill is 0327 or 0329 and the From Date is not equal to the Admission Date, and no revenue code 042x, 043x, 044x or 055x line with covered charges is present upon receipt of the claim, and condition code 20, 21 or 54 is not present and the claim receipt date is on or after July 1, This revises the criteria for CR9474 in order to exclude lines for which charges are moved from covered to non-covered during adjudication. Medicare has determined the remittance advice code pair used when the HH outlier limit is applied is not compliant with industry standards. The Remittance Advice Remark Code (RARC) that was created for 14 12/2016

16 this policy, N523, is no longer part of any compliant code pair and will no longer be used. When an outlier amount is withheld due to the HH outlier limitation policy, MACs will use Group Code CO and Claim Adjustment Reason Code (CARC) 119. Additional Information The official instruction, CR9826, issued to your MAC regarding this change is available at cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r3630cp.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. Denial of Home Health Payments When Required Patient Assessment Is Not Received MLN Matters Number: MM9585 Related Change Request (CR) #: CR 9585 Related CR Release Date: October 27, 2016 Effective Date: April 1, 2017 Related CR Transmittal #: R3629CP Implementation Date: April 3, 2017 Provider Types Affected This MLN Matters Article is intended for Home Health Agencies (HHAs) submitting claims to Medicare Administrative Contractors (MACs) for home health services provided to Medicare beneficiaries. Provider Action Needed Change Request (CR) 9585 directs MACs to automate the denial of Home Health Prospective Payment System (HH PPS) claims when the condition of payment for submitting patient assessment data has not been met. Make sure that your billing staffs are aware of this change. Background Per the Code of Federal Regulations (CFR) at 42 CFR (e) ( title42-vol5/pdf/CFR-2011-title42-vol5-part484.pdf), submission of an Outcome and Assessment Information Set (OASIS) assessment for all Home Health (HH) episodes of care is a condition of payment. If the OASIS is not found during medical review of an HH claim, the claim is denied. Original Medicare systems validate the HIPPS code submitted on an HH claim against the HIPPS code calculated by when the OASIS assessment is received in the Quality Information Evaluation System (QIES). If the codes do not match, the HIPPS code calculated from the OASIS assessment is used for payment. Currently, Medicare systems take no action on claims when the OASIS assessment is not found. The Office of Inspector General (OIG) has recommended that Medicare strengthen its enforcement of OASIS as a condition of payment. In Medicare s response to OIG report OEI ( hhs.gov/oei/reports/oei asp), the Centers for Medicare & Medicaid Services (CMS) stated its intention to use the claims-oasis interface to do this /2016

17 Medicare implemented the initial stage in April Medicare informed providers through the MLN Matters Special Edition article SE1504 ( Learning-Network-MLN/MLNMattersArticles/Downloads/SE1504.pdf). In that article, Medicare also notified HHAs that CMS plans to use the claims matching process to enforce this condition of payment in the earliest available Medicare systems release. At that time, Medicare will deny claims when a corresponding assessment is past due in the QIES but is not found in that system. CR9585 provides MACs with requirements to implement this next step. When an OASIS Assessment Has Not Been Submitted As mentioned above, submission of an OASIS assessment is a condition of payment for HH episodes of care. OASIS reporting regulations require the OASIS to be transmitted within 30 days of completing the assessment of the beneficiary. In most cases, this 30-day period will have elapsed by the time a 60-day episode of HH services is completed and the HHA submits the final claim for that episode to Medicare. If the OASIS assessment is not found in the QIES upon receipt of a final claim for an HH episode and the receipt date of the claim is more than 30 days after the assessment completion date, Medicare systems will deny the HH claim. (While the regulation requires the assessment to be submitted within 30 days, the initial implementation of this edit will allow 40 days.) In denying the claim, Medicare will supply the following remittance messages: Group Code of CO Claim Adjustment Reason Code 272 Additional Information The official instruction, CR9585, issued to your MAC regarding this change is available at cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r3629cp.pdf. The revised portion of Chapter 10 of the Medicare Claims Processing Manual discusses this change further and that manual portion is attached to CR9585. If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. Implementation of Policy Changes for the CY 2017 Home Health Prospective Payment System MLN Matters Number: MM9736 Related Change Request (CR) #: CR 9736 Related CR Release Date: November 10, 2016 Effective Date: January 1, 2017 Related CR Transmittal #: R3655CP Implementation Date: January 3, /2016

18 Provider Types Affected This MLN Matters Article is intended for physicians, other providers, and suppliers submitting claims to Medicare contractors (fiscal intermediaries (FIs), carriers, Regional Home Health Intermediaries (RHHIs) and A/B Medicare Administrative Contractors (A/B MACs)) for services to Medicare beneficiaries. Provider Action Needed STOP Impact to You This article is based on Change Request (CR) 9736 which informs Medicare contractors about the implementation of a separate payment for home health agencies (HHAs) for disposable Negative Pressure Wound Therapy (NPWT) devices when furnished to a patient who receives home health services for which payment is made under the Medicare home health benefit. In addition, CR9736 will do the following: Implement changes to the methodology used to calculate outlier payments to HHAs and Create new G codes associated with registered nurse (RN) and licensed practical nurse (LPN) visits in the home health setting. GO What You Need to Do Make sure that your billing staffs are aware of these changes. See the Background and Additional Information Sections of this article for further details regarding these changes. Background Provision of NPWT Using a Disposable Device The Consolidated Appropriations Act of 2016 (Pub. L ) requires a separate payment to be made to Home Health Agencies (HHAs) for disposable NPWT devices when furnished, on or after January 1, 2017, to an individual who receives home health services for which payment is made under the Medicare home health benefit. Key points in CR9736 Change in the Methodology Used to Calculate Outlier Payments Currently, the Centers for Medicare and Medicaid Services (CMS) calculates the estimated cost for an episode using the number of visits by discipline and multiplying them by the national per-visit rates finalized in our rules. The Report to Congress on home health access to care and payment for vulnerable patient populations (required per Section 3131(d) of the Affordable Care Act), indicated that HHAs can make a profit on outlier episodes by providing shorter visits than what is assumed in the national per-visit rates. Therefore, the current methodology for calculating the cost of an episode of care potentially overestimates the costs associated with an episode where shorter visits are provided than is assumed in the national pervisit rates. In addition, the study findings noted that certain types of patients may be associated with lower margins, such as those who require parenteral nutrition or require substantial assistance with bathing. These types of patients, on average, typically require longer visits and are thus more costly to treat /2016

19 Analysis of calendar year 2015 data indicates that there is significant variation in the visit length by discipline for outlier episodes. Those agencies with 5 percent or more of their total payments as outlier payments are providing shorter but more frequent skilled nursing visits than agencies with less than 5 percent of their total payments as outlier payments. Creation of New G Codes for RN and LPN In Home Health Episodes Effective for January 1, 2016, CMS divided the G0154 code into two different codes (codes G0299 and G0300) that differentiate RN from LPN and may be used in both HH and hospice settings. This change was made in order to furnish a hospice add-on payment that is only payable for RN visits (not LPN visits) through the Service Intensity Add-on Payment. As of CY 2015, CMS now annually recalibrates the HH case-mix weights. The weights are determined by calculating the cost for each episode of care, grouping the episodes by similar levels of resource use, and comparing the group s average resource use to overall mean. The cost of an episode of care is calculated using the BLS average hourly wage rate for the discipline that performed the visit multiplied by the minutes per visit reported on the HH claim. Currently, CMS has separate G-codes for therapist versus therapist assistant visits so they are able to use the appropriate BLS average hourly wage rate depending on whether the visit was performed by a therapist or an assistant. However, for skilled nursing services, because G0163 and G0164 are for an RN or LPN, CMS has to assume a certain percentage are performed by a RN versus an LPN. Since CMS has begun differentiating direct skilled nursing using the two new G-codes (codes G0299 and G0300), CMS believes it is appropriate to differentiate G0163 and G0164 as well so that there is no longer a need to use an assumption in calculating the cost per episode when those two services are performed, allowing for increased payment precision. Provision of NPWT Using a Disposable Device As described in the Consolidated Appropriations Act of 2016 (Pub. L ), the separate payment amount for an applicable disposable device will be set equal to the amount of the payment that would otherwise be made under the Medicare Hospital Outpatient Prospective Payment System (OPPS) using the Level I Healthcare Common Procedure Coding System (HCPCS) code, otherwise referred to as Current Procedural Terminology (CPT-4) codes. Currently CPT codes and (APC 5052), with status indicator T (Procedure or Service, Multiple Procedure Reduction Applies), include payment for both performing the service and the disposable NPWT device: HCPCS Negative pressure wound therapy, (e.g., vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters. HCPCS Negative pressure wound therapy, (e.g., vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters /2016

20 To avoid duplication of payment, for instances where the sole purpose for an HHA visit is to perform NPWT using a disposable device (integrated system of a vacuum pump, receptacle for collecting exudate, and dressings for the purposes of wound therapy), Medicare will not pay for a skilled nursing or therapy visit under the HH PPS. Rather, performing NPWT using a disposable device for a patient under a home health plan of care is being separately reimbursed the OPPS amount relating to payment for covered OPD services. In this situation, the HHA bills under type of bill 034x and reports the appropriate revenue code (0559, 042X, 043X), along with the appropriate HCPCS code (97607 or 97608). NOTE: This visit is not reported on the HH PPS claim (type of bill 32x). If NPWT using a disposable device is performed during the course of an otherwise covered home health visit (e.g., to perform a catheter change), the visit would be covered as normal but the HHA must not include the time spent performing NPWT in their visit charge or in the length of time reported for the visit. Performing NPWT using a disposable device for a patient under a home health plan of care will be separately reimbursed the OPPS amount relating to payment for covered OPD services. In this situation, the HHA bills under type of bill 34X and reports revenue code (0559, 042X, 043X) along with the appropriate HCPCS code (97607 or 97608). NOTE: This visit is also reported on the HH PPS claim (type of bill 32x). Denial Message When a claim with HCPCS and on TOB 034x is identified as not falling within a HH episode, your MAC will deny lines reporting revenue code 0559 (Skilled Nursing Care, Comprehensive Visit) using the following remittance advice codes: Group Code: CO CARC: 170 (Payment is denied when performed/billed by this type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.) RARC: N95 (Services subjected to Home Health Initiative medical review/cost report audit.) Change in the Methodology Used to Calculate Outlier Payments Given the analysis described above, as well as the findings from the 3131(d) study, CMS is concerned the current methodology for calculating outlier payments creates a financial disincentive for providers to treat medically complex beneficiaries that require longer visits. In addition, the current methodology does not accurately calculate the precise cost of an episode of care for instances where the length of the visit is greater than or less than the average length of a visit assumed in the national per visit rates. Therefore, CMS is changing the methodology used to calculate outlier payments to a cost per unit approach rather than a cost per visit approach. HHAs currently report visit lengths in 15 minute increments (15 minutes = 1 unit). To implement this new methodology, the national per visit rates will be converted into per unit rates (as described in Attachment 1 in CR9367). The new per unit rates will then be used to calculate the estimated cost of an episode to determine whether the claim will receive an outlier payment and the amount of payment for an episode of 19 12/2016

21 care. This change in the methodology will be budget neutral as CMS would still target to pay up to, but no more than, 2.5 percent of total HH PPS payments as outlier payments. In conjunction with the change to a cost-per unit approach to estimate episode costs and determine whether an outlier episode should receive outlier payments, CMS is implementing a cap on the amount of time per day that would be counted toward the estimation of an episode s costs for outlier calculation purposes, limiting the amount of time per day (summed across the six disciplines of care) at 8 hours or 32 units total. For rare instances when more than one discipline of care is provided and there is more than 8 hours of care provided in one day, the episode cost associated with the care provided during that day will be calculated using a hierarchical method based on the cost per unit per discipline. The discipline of care with the lowest associated cost per unit will be discounted in the calculation of episode cost in order to cap the estimation of an episode s cost at 8 hours of care per day. Creation of New G Codes for RN and LPN in Home Health Episodes Given the reporting needs articulated above, CMS is requesting that G0163 and G0164 be retired, effective January 1, 2017, and instead replaced with four new G-codes: 1. G Skilled services of a registered nurse (RN) for the observation and assessment of the patient s condition, each 15 minutes (the change in the patient s condition requires skilled nursing personnel to identify and evaluate the patient s need for possible modification of treatment in the home health or hospice setting). 2. G Skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patient s condition, each 15 minutes (the change in the patient s condition requires skilled nursing personnel to identify and evaluate the patient s need for possible modification of treatment in the home health or hospice setting). 3. G Skilled services of a registered nurse (RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes. 4. G Skilled services of a licensed practical nurse (LPN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes. Additional Information The official instruction, CR 9736, issued to your MAC regarding this change is available at cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r3655cp.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/ /2016

22 Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2017 MLN Matters Number: MM9820 Related Change Request (CR) #: CR 9820 Related CR Release Date: October 14, 2016 Effective Date: January 1, 2017 Related CR Transmittal #: R3624CP Implementation Date: January 3, 2017 Provider Types Affected This MLN Matters Article is intended for Home Health Agencies (HHAs) submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. Provider Action Needed Change Request (CR) 9820 updates the national, standardized 60-day episode rates, the national per-visit rates, and the non-routine medical supply payment amounts under the HH PPS for Calendar Year (CY) Make sure your billing staff are aware of these changes. Background The Affordable Care Act (Section 3131(a)) mandates that starting in CY 2014, the Centers for Medicare & Medicaid Services (CMS) must apply an adjustment to the national, standardized 60-day episode payment rate and other amounts applicable under the Social Security Act (Section 1895(b)(3)(A)(i)(III)) to reflect factors such as changes in the number of visits in an episode, the mix of services in an episode, the level of intensity of services in an episode, the average cost of providing care per episode, and other relevant factors. The Affordable Care Act (Section 3131(a)) mandates that this rebasing must be phased-in over a 4-year period in equal increments, not to exceed 3.5 percent of the amount (or amounts), as of the date of enactment, applicable under the Social Security Act (Section 1895(b)(3)(A)(i)(III)), and be fully implemented by CY In addition, the Affordable Care Act (Section 3401(e)) requires that the market basket percentage under the HH PPS be annually adjusted by changes in economy-wide productivity for CY 2015 and each subsequent calendar year. The Medicare Modernization Act (MMA; Section 421(a)) ( 108publ173/content-detail.html), as amended by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; Pub. L ; Section 210) ( htm), provides an increase of 3 percent of the payment amount otherwise made under the Social Security Act (Section 1895) for home health services furnished in a rural area (as defined in the Social Security Act (Section 1886(d)(2)(D)), with respect to episodes and visits ending on or after April 1, 2010 and before January 1, The statute waives budget neutrality related to this provision, as the statute specifically states that CMS will not reduce the standard prospective payment amount (or amounts) under the Social Security Act (Section 1895) applicable to home health services furnished during a period to offset the increase in payments resulting in the application of this section of the statute /2016

23 Market Basket Update The CY 2017 HH market basket update is 2.8 percent which is then reduced by a multi-factor productivity (MFP) adjustment of 0.3 percentage points. The resulting home health (HH) payment update is equal to 2.5 percent. HHAs that do not report the required quality data will receive a 2 percentage point reduction to the HH payment update. National, Standardized 60-Day Episode Payment As described in the CY 2017 HH PPS final rule, in order to calculate the CY 2017 national, standardized 60-day episode payment rate, CMS applies a wage index budget neutrality factor of and a case-mix budget neutrality factor of to the previous calendar year s national, standardized 60-day episode rate. In order to account for nominal case-mix growth from CY 2012 to CY 2014, CMS applies a payment reduction of 0.97 percent to the national, standardized 60-day episode payment rate. CMS then applies an $80.95 rebasing reduction (which is 3.5 percent of the CY 2010 national, standardized 60-day episode rate of $2,312.94) to the national, standardized 60-day episode rate. Lastly, the national, standardized 60-day episode payment rate is updated by the CY 2017 HH payment update percentage of 2.5 percent for HHAs that submit the required quality data and by 2.5 percent minus 2 percentage points, or 0.5 percent, for HHAs that do not submit quality data. These two episode payment rates are shown in Table 1 and Table 2. These payments are further adjusted by the individual episode s case-mix weight and by the wage index. Table 1: For HHAs that DO Submit Quality Data National, Standardized 60-Day Episode Amount for CY 2017 CY 2016 National, Standardized 60-Day Episode Payment Wage Index Budget Neutrality Factor Case-Mix Weights Budget Neutrality Factor Nominal Case-Mix Growth Adjustment CY 2017 Rebasing Adjustment CY 2017 HH Payment Update CY 2017 National, Standardized 60-Day Episode Payment $2, X X X $80.95 X $2, Table 2: For HHAs that DO NOT Submit Quality Data National, Standardized 60-Day Episode Amount for CY 2017 CY 2016 National, Standardized 60-Day Episode Payment Wage Index Budget Neutrality Factor Case-Mix Weights Budget Neutrality Factor Nominal Case-Mix Growth Adjustment CY 2017 Rebasing Adjustment CY 2017 HH Payment Update Minus 2 Percentage Points CY 2017 National, Standardized 60-Day Episode Payment $2, X X X $80.95 X $2, /2016

24 National Per-Visit Rates In order to calculate the CY 2017 national per-visit payment rates, CMS starts with the CY 2016 national per-visit rates. CMS applies a wage index budget neutrality factor of to ensure budget neutrality for low utilization payment adjustment (LUPA) per-visit payments after applying the CY 2017 wage index, and then applies the maximum rebasing adjustments to the per-visit rates for each discipline. The per-visit rates are then updated by the CY 2017 HH payment update of 2.5 percent for HHAs that submit the required quality data and by 0.5 percent for HHAs that do not submit quality data. The per-visit rates are shown in Table 3 and Table 4. Table 3: For HHAs that DO Submit Quality Data CY 2017 National Per-Visit Amounts for LUPAs and Outlier Calculations HH Discipline Type Home Health Aide Medical Social Services Occupational Therapy Physical Therapy Skilled Nursing Speech- Language Pathology CY 2016 Per-Visit Payment Wage Index Budget Neutrality Factor CY 2017 Rebasing Adjustment CY 2017 HH Payment Update $60.87 X $1.79 X $64.23 CY 2017 Per- Visit Payment $ X $6.34 X $ $ X $4.35 X $ $ X $4.32 X $ $ X $3.96 X $ $ X X $ Table 4: For HHAs that DO NOT Submit Quality Data CY 2017 National Per-Visit Amounts for LUPAs and Outlier Calculations HH Discipline Type Home Health Aide CY 2016 Per-Visit Payment Wage Index Budget Neutrality Factor CY 2017 Rebasing Adjustment CY 2017 HH Payment Update $60.87 X $1.79 X $62.97 CY 2017 Per- Visit Payment 23 12/2016

25 Medical Social Services Occupational Therapy Physical Therapy Skilled Nursing Speech- Language Pathology $ X $6.34 X $ $ X $4.35 X $ $ X $4.32 X $ $ X $3.96 X $ $ X X $ Non-Routine Supply Payments Payments for non-routine supplies (NRS) are computed by multiplying the relative weight for a particular NRS severity level by an NRS conversion factor. To determine the CY 2017 NRS conversion factors, CMS starts with the CY 2016 NRS conversion factor and applies a 2.82 percent rebasing adjustment as described in the CY 2017 HH PPS final rule. CMS then updates the conversion factor by the CY 2017 HH payment update of 2.5 percent for HHAs that submit the required quality data and by 0.5 percent for HHAs that do not submit quality data. CMS does not apply any standardization factors as the NRS payment amount calculated from the conversion factor is neither wage nor case-mix adjusted when the final payment amount is computed. The NRS conversion factor for CY 2017 payments for HHAs that do submit the required quality data is shown in Table 5a and the payment amounts for the various NRS severity levels are shown in Table 5b. The NRS conversion factor for CY 2017 payments for HHAs that do not submit quality data is shown in Table 6a and the payment amounts for the various NRS severity levels are shown in Table 6b. Table 5a: CY 2017 NRS Conversion Factor for HHAs that DO Submit the Required Quality Data CY 2016 NRS Conversion Factor CY 2017 Rebasing Adjustment CY 2017 HH Payment Update $52.71 X X $52.50 CY 2017 NRS Conversion Factor Table 5b: CY 2017 Relative Weights and Payment Amounts for the 6-Severity NRS System for HHAs that DO Submit Quality Data Severity Level Points (Scoring) Relative Weight CY 2017 NRS Payment Amounts $ to $ to $ to $ /2016

26 5 49 to $ $ Table 6a: CY 2017 NRS Conversion Factor for HHAs that DO NOT Submit the Required Quality Data CY 2016 NRS Conversion Factor CY 2017 Rebasing Adjustment CY 2017 HH Payment Update Percentage Minus 2 Percentage Points $52.71 X X $51.48 CY 2017 NRS Conversion Factor Table 6b: CY 2017 Relative Weights and Payment Amounts for the 6-Severity NRS System for HHAs that DO NOT Submit Quality Data Severity Level Points (Scoring) Relative Weight CY 2017 NRS Payment Amounts $ to $ to $ to $ to $ $ Rural Add-On As stipulated in the MMA (Section 421(a)), the 3 percent rural add-on is applied to the national, standardized 60-day episode rate, national per-visit payment rates, LUPA add-on payments, and the NRS conversion factor when home health services are provided in rural (non-cbsa) areas for episodes and visits ending on or after April 1, 2010, and before January 1, Refer to Table 7, Table 8, Table 9a and Table 9b which follow below for the CY 2017 rural payment rates /2016

27 Table 7: CY 2017 National, Standardized 60-Day Payment Amounts for Services Provided in a Rural Area For HHAs that DO Submit Quality Data CY 2017 National, Standardized 60-Day Episode Payment Rate Multiply by the 3 Percent Rural Add- On CY 2017 Rural National, Standardized 60-Day Episode Payment Rate For HHAs that DO NOT Submit Quality Data CY 2017 National, Standardized 60-Day Episode Payment Rate Multiply by the 3 Percent Rural Add- On CY 2017 Rural National, Standardized 60-Day Episode Payment Rate $2, X 1.03 $3, $2, X 1.03 $3, Table 8: CY 2017 National Per-Visit Amounts for Services Provided in a Rural Area HH Discipline Type For HHAs that DO submit quality data CY 2017 Per-visit rate Multiply by the 3 Percent Rural Add-On CY 2017 Rural Per-Visit Rates For HHAs that DO NOT submit quality data CY 2017 Per-visit rate Multiply by the 3 Percent Rural Add-On CY 2017 Rural Per- Visit Rates HH Aide $64.23 X 1.03 $66.16 $62.97 X 1.03 $64.86 MSS $ X 1.03 $ $ X 1.03 $ OT $ X 1.03 $ $ X 1.03 $ PT $ X 1.03 $ $ X 1.03 $ SN $ X 1.03 $ $ X 1.03 $ SLP $ X 1.03 $ $ X 1.03 $ Table 9a: CY 2017 NRS Conversion Factor for Services Provided in Rural Areas For HHAs that DO submit quality data For HHAs that DO NOT submit quality data CY 2017 Conversion Factor Multiply by the 3 Percent Rural Add-On CY 2017 Rural NRS Conversion Factor CY 2017 Conversion Factor Multiply by the 3 Percent Rural Add- On CY 2017 Rural NRS Conversion Factor $52.50 X 1.03 $54.08 $51.48 X 1.03 $ /2016

28 Table 9b: CY 2017 Relative Weights and Payment Amounts for the 6-Severity NRS System for Services Provided in Rural Areas Severity Level Points (Scoring) For HHAs that DO submit quality data Relative CY 2017 Weight NRS Payment Amounts for Rural Areas For HHAs that DO NOT submit quality data Relative CY 2017 Weight NRS Payment Amounts for Rural Areas $ $ to $ $ to $ $ to $ $ to $ $ $ $ These changes are implemented through the Home Health Pricer software in Medicare s shared systems. Additional Information The official instruction, CR 9820, issued to your MAC regarding this change is available at cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r3624cp.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. Comprehensive Care for Joint Replacement Model (CJR) Provider Education MLN Matters Number: MM9533 Revised Related Change Request (CR) #: CR 9533 Related CR Release Date: February 19, 2016 Effective Date: April 1, 2016 Implementation Date: April 4, 2016 Related CR Transmittal #: R140DEMO Note: This article was revised on November 9, 2016, to correct a typo in the list of G-codes in the lower half of page 6. The original article mentioned code G9499 and it should have stated G9489. All other information remains the same /2016

29 Provider Types Affected This MLN Matters Article is intended for physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for Comprehensive CJR services provided to Medicare beneficiaries. What You Need to Know Change Request (CR) 9533 supplies information to providers about the CJR model. The intent of the CJR model is to promote quality and financial accountability for episodes of care surrounding a Lower-Extremity Joint Replacement (LEJR) or reattachment of a lower extremity procedure. CJR will test whether bundled payments to certain acute care hospitals for LEJR episodes of care will reduce Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries. Make sure that your billing staffs are aware of these changes. Background Section 1115A of the Social Security Act (the Act) authorizes the Centers for Medicare & Medicaid Services (CMS) to test innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care furnished to Medicare, Medicaid, and Children s Health Insurance Program beneficiaries. Under this authority, CMS published a rule to implement a new five year payment model called the Comprehensive Care for Joint Replacement (CJR) model on April 1, Under the CJR model, acute care hospitals in certain selected geographic areas will take on quality and payment accountability for retrospectively calculated bundled payments for LEJR episodes. Episodes will begin with admission to an acute care hospital for an LEJR procedure that is paid under the Inpatient Prospective Payment System (IPPS) through Medical Severity Diagnosis-Related Group (MS-DRG) 469 (Major joint replacement or reattachment of lower extremity with MCC) or 470 (Major joint replacement or reattachment of lower extremity without MCC) and end 90 days after the date of discharge from the hospital. Key Points of CR9533 CJR Episodes of Care LEJR procedures are currently paid under the IPPS through: MS-DRG 469 or MS-DRG 470. The episode will include the LEJR procedure, inpatient stay, and all related care covered under Medicare Parts A and B within the 90 days after discharge. The day of discharge is counted as the first day of the 90-day bundle. CJR Participant Hospitals The model requires all hospitals paid under the IPPS in selected geographic areas to participate in the CJR model, with limited exceptions. A list of the selected geographic areas and participant hospitals is available at on the Internet. Participant hospitals initiate episodes when an LEJR procedure is performed within the hospital and will be at financial risk for the cost of the services included in the bundle. Eligible beneficiaries who elect to receive care at these hospitals will automatically be included in the model /2016

30 CJR Model Beneficiary Inclusion Criteria Medicare beneficiaries whose care will be included in the CJR model must meet the following criteria upon admission to the anchor hospitalization: The beneficiary is enrolled in Medicare Part A and Part B; The beneficiary s eligibility for Medicare is not on the basis of the End-Stage Renal Disease benefit; The beneficiary is not enrolled in any managed care plan; The beneficiary is not covered under a United Mine Workers of America health plan; and Medicare is the primary payer. If at any time during the episode the beneficiary no longer meets all of these criteria, the episode is canceled. CJR Performance Years CMS will implement the CJR model for 5 performance years, as detailed in the table below. Performance years for the model correlate to calendar years with the exception of performance year 1, which is April 1, 2016, through December 31, CJR Model: 5 Performance Years Performance Year Performance Year 1 (calendar year 2016) Performance Year 2 (calendar year 2017) Performance Year 3 (calendar year 2018): Performance Year 4 (calendar year 2019): Performance Year 5 (calendar year 2020): Date for Episodes Episodes that start on or after April 1, 2016, and end on or before December 31, 2016 Episodes that end between January 1, 2017, and December 31, 2017, inclusive Episodes that end between January 1, 2018, and December 31, 2018, inclusive Episodes that end between January 1, 2019, and December 31, 2019, inclusive Episodes that end between January 1, 2020, and December 31, 2020, inclusive CJR Episode Reconciliation Activities CMS will continue paying hospitals and other providers and suppliers according to the usual Medicare fee-for-service payment systems during all performance years. After completion of a performance year, Medicare will compare or reconcile actual claims paid for a beneficiary during the 90 day episode to an established target price. The target price is an expected amount for the total cost of care of the episode. Hospitals will receive separate target prices to reflect expected spending for episodes assigned to MS-DRGs 29 12/2016

31 469 and 470, as well as hip fracture status. If the actual spending is lower than the target price, the difference will be paid to the hospital, subject to certain adjustments, such as for quality. This payment will be called a reconciliation payment. If actual spending is higher than the target price, hospitals will be responsible for repayment of the difference to Medicare, subject to certain adjustments, such as for quality. Identifying CJR Claims To validate the retroactive identification of CJR episodes, CMS is associating the Demonstration Code 75 with the CJR initiative. This code will also be utilized in future CRs to operationalize a waiver of the three-day stay requirement for covered Skilled Nursing Facility (SNF) services, effective for CJR episodes beginning on or after January 1, Medicare will automatically apply the CJR demonstration code to claims meeting the criteria for inclusion in the demonstration. Participant hospitals need not include demonstration code 75 on their claims. Instructions for submission of claims for SNF services rendered to beneficiaries in a CJR episode of care will be communicated once the waiver of the three-day stay requirement is operationalized. Waivers and Amendments of Medicare Program Rules The CJR model waives certain existing payment system requirements to provide additional flexibilities to hospitals participating in CJR, as well as other providers that furnish services to beneficiaries in CJR episodes. The purpose of such flexibilities would be to increase LEJR episode quality and decrease episode spending or provider and supplier internal costs, or both, and to provide better, more coordinated care for beneficiaries and improved financial efficiencies for Medicare, providers, and beneficiaries. Post-Discharge Home Visits In order for Medicare to pay for home health services, a beneficiary must be determined to be home bound. A beneficiary is considered to be confined to the home if the beneficiary has a condition, due to an illness or injury, that restricts his or her ability to leave home except with the assistance of another individual or the aid of a supportive device (that is, crutches, a cane, a wheelchair or a walker) or if the beneficiary has a condition such that leaving his or her home is medically contraindicated. Additional information regarding the homebound requirement is available in the Medicare Benefit Policy Manual; Chapter 7 ( pdf), Home Health Services, Section , Patient Confined to the Home. Medicare policy allows physicians and Non-Physician Practitioners (NPPs) to furnish and bill for visits to any beneficiary s home or place of residence under the Medicare Physician Fee Schedule (MPFS). Medicare policy also allows such physicians and practitioners to bill Medicare for services furnished incident to their services by licensed clinical staff. Additional information regarding the incident to requirements is available in 42 CFR ( title42-vol2-sec pdf) /2016

32 For those CJR beneficiaries who could benefit from home visits by licensed clinical staff for purposes of assessment and monitoring of their clinical condition, care coordination, and improving adherence with treatment, CMS will waive the incident to direct physician supervision requirement to allow a beneficiary who does not qualify for Medicare home health services to receive post-discharge visits in his or her home or place of residence any time during the episode, subject to the following conditions: Licensed clinical staff will provide the service under the general supervision of a physician or NPP. These staff can come from a private physician office or may be either an employee or a contractor of the participant hospital. Services will be billed under the MPFS by the supervising physician or NPP or by the hospital or other party to which the supervising physician has reassigned his or her billing rights. Up to 9 post discharge home visits can be billed and paid per beneficiary during each CJR episode, defined as the 90-day period following the anchor hospitalization. The service cannot be furnished to a CJR beneficiary who has qualified, or would qualify, for home health services when the visit was furnished. All other Medicare rules for coverage and payment of services incident to a physician s service continue to apply. As described in the Medicare Claims Processing Manual, Chapter 12 ( Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf), Sections , Medicare policy generally does not allow for separate billing and payment for a postoperative visit furnished during the global period of a surgery when it is related to recovery from the surgery. However, for CJR, CMS will allow the surgeon or other practitioners to bill and be paid separately for a post-discharge home visit that was furnished in accordance with these conditions. All other Medicare rules for global surgery billing during the 90 day post-operative period continue to apply. CMS expects that the post-discharge home visits by licensed clinical staff could include patient assessment, monitoring, assessment of functional status and fall risk, review of medications, assessment of adherence with treatment recommendations, patient education, communication and coordination with other treating clinicians, and care management to improve beneficiary connections to community and other services. The service will be billed under the MPFS with a HCPCS G-code (G9490) specific to the CJR postdischarge home visit, as listed in Attachment A. The post-discharge home visit HCPCS code will be payable for CJR model beneficiaries beginning April 1, 2016, the start date of the first CJR model performance year. Claims submitted for post-discharge home visits for the CJR model will be accepted only when the claim contains the CJR specific HCPCS G-Code. Although CMS is associating the Demonstration Code 75 with the CJR initiative, no demonstration code is needed or required on Part B claims submitted with the postdischarge home visit HCPCS G-Code /2016

33 Additional information on billing and payment for the post-discharge home visit HCPCS G-Code will be available in the April 2016 release of the MPFS Recurring Update. Future updates to the relative value units (RVUs) and payment for this HCPCS code will be included in the MPFS final rules and recurring updates each year. Billing and Payment for Telehealth Services Medicare policy covers and pays for telehealth services when beneficiaries are located in specific geographic areas. Within those geographic areas, beneficiaries must be located in one of the health care settings that are specified in the statute as eligible originating sites. The service must be on the list of approved Medicare telehealth services. Medicare pays a facility fee to the originating site and provides separate payment to the distant site practitioner for the service. Additional information regarding Medicare telehealth services is available in the Medicare Benefit Policy Manual, Chapter 15 ( Section 270 and the Medicare Claims Processing Manual, Chapter 12 ( Downloads/clm104c12.pdf), Section 190. Under CJR, CMS will allow a beneficiary in a CJR episode in any geographic area to receive services via telehealth. CMS also will allow a home or place of residence to be an originating site for beneficiaries in a CJR episode. This will allow payment of claims for telehealth services delivered to beneficiaries at eligible originating sites or at their residence, regardless of the geographic location of the beneficiary. CMS will waive these telehealth requirements, subject to the following conditions: Telehealth services cannot substitute for in-person home health visits for patients under a home health episode of care. Telehealth services performed by social workers for patients under a home health episode of care will not be covered under the CJR model. The telehealth geographic area waiver and the allowance of home as an originating site under the CJR model does not apply for instances where a physician or allowed NPP is performing a face-to-face encounter for the purposes of certifying patient eligibility for the Medicare home health benefit. The principal diagnosis code reported on the telehealth claim cannot be one that is specifically excluded from the CJR episode definition. If the beneficiary is at home, the physician cannot furnish any telehealth service with a descriptor that precludes delivering the service in the home (for example, a hospital visit code). If the physician is furnishing an evaluation and management visit via telehealth to a beneficiary at home, the visit must be billed by one of nine unique HCPCS G-codes developed for the CJR model that reflect the home setting. For CJR telehealth home visits billed with HCPCS codes G9484, G9485, G9488, and G9489, the physician must document in the medical record that auxiliary licensed clinical staff were available on site in the patient s home during the visit or document the reason that such a high-level visit would not require such personnel /2016

34 Physicians billing distant site telehealth services under these waivers must include the GT modifier on the claim, which attests that the service was furnished in accordance with all relevant coverage and payment requirements. The facility fee paid by Medicare to an originating site for a telehealth service will be waived if the service was originated in the beneficiary s home. The telehealth home visits will be billed under the MPFS with one of nine HCPCS G-code specific to the CJR telehealth home visits. Those codes are G9481, G9482, G9483, G9484, G9485, G9586, G9487, G9488, and G9489. Attachment A of CR9533 provides the long descriptors of these codes. The telehealth home visit HCPCS codes will be payable for CJR model beneficiaries beginning April 1, 2016, the start date of the first CJR model performance year. Claims submitted for telehealth home visits for the CJR model will be accepted only when the claim contains one of nine of the CJR specific HCPCS G-Code. Although CMS is associating the Demonstration Code 75 with the CJR initiative, no demonstration code is needed or required on Part B claims submitted with the post-discharge home visit HCPCS G-Code. Additional information on billing and payment for the telehealth home visit HCPCS G-Codes will be available in the April 2016 release of the MPFS Recurring Update. Future updates to the RVUs and payment for these HCPCS codes will be included in the MPFS final rules and recurring updates each year. Additional Information The official instruction, CR9533, issued to your MAC regarding this change is available at cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r140demo.pdf on the CMS website. If you have any questions, please contact your MAC at their toll-free number. That number is available at MLNMattersArticles/index.html under - How Does It Work. Document History November 9, article revised to correct typo and to show correct code of G9489 on page 6 February 22, initial issuance eservices Makes Asking a Medicare Question Easier! Palmetto GBA is pleased to announce the newest addition to our eservice options---secure echat! This innovative feature allows providers to interact with designated Palmetto GBA staff so they can receive realtime assistance locating information on any topics or specialties they are searching for on the Palmetto GBA website or within the eservices online portal. The Secure echat feature also allows users to dialogue with an online operator who can assist with patient or provider specific inquires or address questions that require the sharing of PHI information! Using Secure echat is simple! This free portal is available to all Medicare 33 12/2016

35 providers as long as you have a signed Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA. Once in the eservices portal, from the bottom right corner select either Medicare Inquiries or eservices Help. If you do not have an eservices account, you can get started by clicking this eservices link The Secure echat feature is available during business hours to assist providers. Managing Multiple eservice Accounts Just Got Easier with Account Linking! Palmetto GBA is excited to announce the highly anticipated eservice enhancement- Account Linking! No longer will providers need a separate login for each PTAN and NPI combination. Palmetto GBA now gives users the ability to link their previously assigned eservices user IDs under one default ID. Getting started is simple! Users should log into eservices with the user ID that they wish to designate as their default login ID. This is the user ID that will be used to access the linked accounts. Once the user has successfully logged into eservices, they will select the My Account Tab and then access the Account Linking sub-tab. This will allow the provider to choose the accounts they wish to link. Note: Providers are only able to link active eservices accounts. Once your accounts are linked you will be able to log in, click a drop down menu that lists all your linked NPI and PTAN combinations attached to your ID, and select the individual account you d like to view. For complete step-by-step instructions, please view the eservices User Guide external link ( palmettogba.com/eservicesuserguide). Get Your Medicare News Electronically The Palmetto GBA Medicare listserv is a wonderful communication tool that offers its members the opportunity to stay informed about: Medicare incentive programs Fee Schedule changes New legislation concerning Medicare And so much more! How to register to receive the Palmetto GBA Medicare Listserv: Go to and select Register Now. Complete and submit the online form. Be sure to select the specialties that interest you so information can be sent. Note: Once the registration information is entered, you will receive a confirmation/welcome message informing you that you ve been successfully added to our listserv. You must acknowledge this confirmation within three days of your registration /2016

36 Medicare Learning Network (MLN) Want to stay informed about the latest changes to the Medicare Program? Get connected with the Medicare Learning Network (MLN) the home for education, information, and resources for health care professionals. The Medicare Learning Network is a registered trademark of the Centers for Medicare & Medicaid Services (CMS) and the brand name for official CMS education and information for health care professionals. It provides educational products on Medicare-related topics, such as provider enrollment, preventive services, claims processing, provider compliance, and Medicare payment policies. MLN products are offered in a variety of formats, including training guides, articles, educational tools, booklets, fact sheets, web-based training courses (many of which offer continuing education credits) all available to you free of charge! The following items may be found on the CMS web page at: index.html MLN Catalog: is a free interactive downloadable document that lists all MLN products by media format. To access the catalog, scroll to the Downloads section and select MLN Catalog. Once you have opened the catalog, you may either click on the title of a product or you can click on the type of Formats Available. This will link you to an online version of the product or the Product Ordering Page. MLN Product Ordering Page: allows you to order hard copy versions of various products. These products are available to you for free. To access the MLN Product Ordering Page, scroll to the Related Links and select MLN Product Ordering Page. MLN Product of the Month: highlights a Medicare provider education product or set of products each month along with some teaching aids, such as crossword puzzles, to help you learn more while having fun! Other resources: MLN Publications List: contains the electronic versions of the downloadable publications. These products are available to you for free. To access the MLN Publications go to: You will then be able to use the Filter On feature to search by topic or key word or you can sort by date, topic, title, or format. MLN Educational Products Electronic Mailing List To stay up-to-date on the latest news about new and revised MLN products and services, subscribe to the MLN Educational Products electronic mailing list! This service is free of charge. Once you subscribe, you will receive an when new and revised MLN products are released /2016

37 To subscribe to the service: 1. Go to and select the Subscribe or Unsubscribe link under the Options tab on the right side of the page. 2. Follow the instructions to set up an account and start receiving updates immediately it s that easy! If you would like to contact the MLN, please CMS at MLN@cms.hhs.gov. CallBack Assist CallBack Assist was implemented to improve the wait times during peak calling periods of the day. CallBack Assist allows providers to opt out for a same-day callback from a customer service representative (CSR). Typically, the callback occurs within one hour. This feature is a contact center best practice among the industry. Providers are encouraged to try this new option when offered to avoid long wait times for assistance. LEARNING AND EDUCATION INFORMATION Quarterly Updates, Changes, and Reminders Webcast December 15, 2016 Palmetto GBA will host the Home Health and Hospice December 2016 Quarterly Updates Webcast on December 15, 2016, at 10 a.m. ET. The Quarterly Update Webcasts are intended to provide ongoing, scheduled opportunities for providers to stay up to date on Medicare requirements. Future quarterly update session dates and times will be added to the registration portal soon. This webcast is designed to provide pertinent updates, changes and reminders to assist the provider community in staying compliant with Medicare rules and regulations and will include: Comprehensive Error Rate Testing (CERT) Medicare Updates and Changes Hot Topics Reminders News to Use! Resources Registration is required. To register for this webcast, please go to the Event Registration Portal under the Learning & Education section of Palmetto GBA website at 6CE7D8DD10B618F3E7883CD4E /2016

38 Note: A National Provider Identifier (NPI) and Provider Transaction Access Number (PTAN) are required to register. You should only enter n/a if you do not have an NPI or PTAN. Audio The audio for this presentation will be broadcasting through your computer. For best results, it is recommended that you utilize/headphones. You will not be able to use your telephone to dial into the conference. Handouts A copy of the presentation will be available once the session begins. Home Health Pre-Claim Review Documentation Requirements Workshops Palmetto GBA is pleased to announce the Home Health Pre-Claim Review Documentation Requirements workshop series. This is the second round of PCR workshops for the demonstration states. This demonstration will apply to: Home Health providers located in Illinois Home Health providers located in Florida Home Health providers located in Texas Home Health providers located in Michigan and Massachusetts These workshops are designed to provide clarity on documentation requirements when submitting for Home Health Pre Claim Review. This is a follow up to the first set of workshops conducted in all three demonstration states that provided an overview of the PCR process and what to expect throughout this demonstration. The following topics will be covered during the workshop: 1. Confined to the Home Criteria 2. Meaning of the F2F Encounter/Clinical Note 3. Physician Certification of Patient Eligibility 4. Certification Requirements: 1. Who can Perform the F2F Encounter 2. Management and Evaluation Narrative 3. Supporting Documentation 5. HCPCS Codes Subject to PCR 37 12/2016

39 6. eservices Portal Decision Tree 7. eservices User Guide and Checklist 8. Required Documentation by Tasks 9. Homebound Documentation 10. Real Examples of Submitted PCR Documentation 11. Tools and Resources Note: CMS requires that Medicare contractors track all educational activities, which consists of capturing the provider s six-digit Provider Transaction Access Number (PTAN) and National Provider Identifier (NPI). Attendees are asked to be prepared to provide this information when they attend the workshop. For workshops that are sponsored by Palmetto GBA, attendees can provide the information during the registration process. Attendees are also encouraged to dress in layers or bring a sweater or jacket to ensure comfort. As a reminder, providers are encouraged to telephone the Provider Contact Center (PCC) at with any claim specific questions they may have as these will not be able to be addressed in the workshop. Featured speakers will be the Provider Outreach and Education (POE) staff that specializes in clinical, as well as billing and coverage experience. How to Register The schedule of workshops can be found in the Event Registration Portal ( event/pgbaevent.nsf/home.xsp) under Learning and Education on the Palmetto GBA Home Health and Hospice webpage ( The state associations are sponsoring these workshops. Please select the link for the date and location of the workshop you want to attend and that will take you directly to the association s registration page /2016

40 MEDICAL POLICY INFORMATION HHH Local Coverage Determinations (LCDs) Updates Revised ICD-10 LCDs The table below provides a summary of recent HHH ICD-10 LCD revisions/updates. To view these revised LCDs, go to Select Active then select Active LCDs under Document types to further refine your search by. Then select the Submit The LCD articles are listed in alphabetical order. Title LCD ID Number Revision Number Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus LCD Number: L35132 Revision Number: 8 Changes/Additions/Deletions Under CMS National Coverage Policy corrected the title for Title XVIII of the Social Security Act, 1814(a)(2)(C) and corrected the section number cited for CMS Internet-Only Manual, Pub , Medicare Benefit Policy Manual, Chapter 7 to now read Under Sources of Information and Basis for Decision-Websites 3. Corrected the title. Effective Date 11/10/ /2016

41 This advisory should be shared with all health care practitioners and managerial members of the provider/ supplier staff. Medicare Advisories are available at no cost from the Palmetto GBA website at www. PalmettoGBA.com/hhh. Address Changes Have you changed your address or other significant information recently? To update this information, please complete and submit a CMS 855A form. The most efficient way to submit your information is by Internet-based Provider Enrollment, Chain and Ownership System (PECOS). To make a change in your Medicare enrollment information via the Internet-based PECOS, go to on the CMS website. To obtain the hard copy form plus information on how to complete and submit it, visit the Palmetto GBA website ( /2016

42 TOOLS THAT YOU CAN USE Medicare Credit Balance Report Module This interactive module provides assistance with completing the Medicare Credit Balance Report (CMS- 838). A credit balance is an improper or excess payment made to a provider as a result of patient billing or claims processing errors. Providers must submit this report quarterly. Failure to submit the report, within 30 days of each quarter end, may result in suspension of payments and your eligibility to participate in the Medicare program. To access the Medicare Credit Balance Report Module on the Palmetto GBA website, select the link below: /2016

43 NOTES 42 12/2016

44 HELPFUL INFORMATION Contact Information for Palmetto GBA Home Health and Hospice Department Contact Information Type of Inquiry Appeals Palmetto GBA Request for HHH Appeals Redeterminations Mail Code: AG-630 Redetermination Form P.O. Box Columbia, SC Fax: (803) Fed Ex/UPS/Certified Mail Address Palmetto GBA HHH Appeals Mail Code: AG-630 Building One 2300 Springdale Drive Camden, SC /2016

45 Contact Center (Providers) Palmetto GBA HHH PCC Mail Code: AG-840 P.O. Box Columbia, SC Provider Contact Center: Our PCC representatives are ready to answer your questions about billing problems and other issues. Please see the following links for more guidance about the HHH Interactive Voice Response (IVR) and contacting the Contact Center: IVR Flowchart: Nsf/files/IVR_HHH_Flowchart.pdf/$File/IVR_HHH_ Flowchart.pdf Call Flowchart: files/ivr_flowchart.pdf/$file/ivr_flowchart.pdf IVR Conversion Tool Main?OpenForm HHH PCC Hours: 8 a.m. to 5 p.m. ET HHH to have your inquiry answered. Please do not include any Protected Health Information. General coverage and Medicare-related questions Crossover questions Questions regarding claim filing requirements Explanation of denial reasons IVR resources MSP resources Modifier guidelines Medical record documentation questions 44 12/2016