Medicare Update

“A quarterly regional publication for health care professionals”
Serving Colorado, Montana, North Dakota, South Dakota, Utah and Wyoming.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services Denver Regional Office
The Pulse o f CMS
interoperability and meaningful use of EHR
technology statewide and, eventually, across the
nation.
The states receiving these funds will use them for
planning activities that include conducting a
comprehensive analysis to determine the current
status of HIT activities in those states. As part of that
process, states will gather information on issues such
as existing barriers to their use of EHRs, provider
eligibility for EHR incentive payments, and the
creation of State Medicaid HIT Plans, which will
define the states‟ vision for their long-term HIT use.
The list below shows the states that have received
these funds and the amounts as of April 30, 2010:
AK $900,000 NE $894,000
AL $269,000 NM $405,000
AR $815,000 NV $1.05 mil
AZ $2.89mil NY $5.91mil
CA $2.48mil OK $587,000
CO $798,000 OR $3.53mil
FL $1.69mil PA $1.42mil
GA $3.17mil PR $1.80mil
IA $1.16mil SC $1.48mil
ID $142,000 TN $2.7mil
IL $2.18mil TX $3.86mil
KS $1.70mil UT $396,000
KY $2.60mil VA $1.66mil
ME $1.40mil VI $232,000
MI $1.52mil VT $294,000
MO $1.53mil WA $967,000
MS $1.47mil WI $1.37mil
MT $239,000 WY $596,000
NC $2.29mil
Physician Fee Schedule
Frozen Until May 31,
2010
In another key step to further states' role in
developing a robust U.S. health information
technology (HIT) infrastructure, CMS announced
that several states‟ Medicaid programs will receive
federal matching funds for state planning activities
necessary to implement the electronic health record
(EHR) incentive program established by the
American Recovery and Reinvestment Act of 2009
(Recovery Act).
EHRs will improve the quality of health care and
make care more efficient. The records make it easier
for the many providers who may be treating a
Medicaid patient to coordinate care. Additionally,
EHRs make it easier for patients to access the
information they need to make decisions about their
health care.
The Recovery Act provides a 90 percent federal
match for state planning activities to administer the
incentive payments to Medicaid providers, to ensure
their proper payments through audits, and to
participate in statewide efforts to promote
States Set to Receive Federal Matching Funds
for EHR Incentive Programs
SPRING 2010
On April 15, 2010, President Obama signed into law
the “Continuing Extension Act of 2010.” This law
extends through May 31, 2010, the zero percent
update to the Medicare physician fee schedule
(MPFS) that was in effect for claims with dates of
service January 1, 2010 through March 31,
2010. The law is retroactive to April 1, 2010.
Consequently, effective immediately, claims with
dates of service April 1, 2010 and later, which were
being held by Medicare contractors, have been
released for processing and payment. Please keep in
mind that the statutory payment floors still apply and,
therefore, clean electronic claims cannot be paid
before 14 calendar days after the date they are
received by Medicare contractors (29 calendar days
for clean paper claims).
Given the uncertainty regarding MPFS claims with
dates of service June 1, 2010, and later, please
watch your listservs and your contractor‟s website for
more information.
Inside this Issue...
PPACA – Timely Filing Requirements ............... 2
PPACA – Ambulance Add-Ons .......................... 2
PPACA – Rural Home Health Services. ............ 2
PPACA – Rural Lab Tests ................................... 2
PPACA – TC of Pathology Services .................. 3
PPACA- Institutional Provisions ......................... 3
PPACA – Therapy Caps Exceptions ................. 3
Physician Supervision in CAHs ........................... 4
Expanded HIV Coverage ..................................... 4
CMS Awards New Banking Contracts ............... 4
The Centers for Medicare & Medicaid Services
(CMS) changed its provider website address from
“www.cms.hhs.gov” to www.cms.gov. Existing
bookmarks and links from other websites will
continue to work following this address change.
Also, the beneficiary-focused website
www.medicare.gov has a new look. Please visit the
site at the above link and refer your Medicare
beneficiary population to the new easy-to-navigate
website.
CMS Website News…New
Address and New Look!
President obama signs the “patient protection and affordable care
act” into law, see pages 2 and 3 for details
The Pulse of CMS Page 2
New Timely Filing
Requirements for Claims
Provider Outreach Staff:
Section 6404 of the PPACA amends the timely filing
requirements to reduce the maximum time period for
submission of all Medicare fee-for-service claims to
one calendar year after the date of service.
Under the new law, claims for services furnished on
or after January 1, 2010, must be filed within one
calendar year after the date of service. In addition,
Section 6404 mandates that claims for services
furnished before January 1, 2010, must be filed no
later than December 31, 2010.
The following rules apply to claims with dates of
service prior to January 1, 2010. Claims with dates of
service before October 1, 2009, must follow the pre-
PPACA timely filing requirements. Claims with dates
of service October 1, 2009, through December 31,
2009, must be submitted by December 31,
2010. The new provision also permits the Secretary
to make certain exceptions to the one-year filing
deadline. At this time, no exceptions have been
established. However, proposals for exceptions will
be specified in future proposed rulemaking.
Extension of Ambulance Add-ons for Ambulance
Services
PPACA Sections 3105 and 10311 impact certain
ambulance payment provisions. It should be noted
that PPACA Section 3105 establishes the
implementation date as April 1, 2010. PPACA
Section 10311 revises Section 3105 and changes the
implementation date retroactive to January 1, 2010.
The PPACA extends the increases in the ambulance
fee schedule amounts for covered ground ambulance
transports which originated in rural areas by 3
percent, and for covered ground ambulance
transports which originated in urban areas by 2
percent retroactive to January 1, 2010, through
December 31, 2010. The new law similarly extends
the provision for air ambulance services provided in
any area that was designated as a rural area for
purposes of making payments under the
ambulance fee schedule for services furnished on
December 31, 2006. Finally, the PPACA extends
retroactive to January 1, 2010, and through December
31, 2010, Section 414 of the Medicare Prescription
Drug, Improvement and Modernization Act of 2003,
which established the super rural bonus.
CMS is working to expeditiously implement these
three ambulance provisions of the PPACA. Be on
the alert for more information about these
ambulance provisions and their impact on your past
and future claims.
Home Health Service in
Rural Areas to Receive
Add-on Payment
Section 3131(c) of PPACA creates a 3 percent addon
to payments made for home health services to
patients in rural areas. The add-on applies to
episodes ending on or after April 1, 2010, through
December 31, 2016. Similar to temporary rural
add-on provisions in the past, claims that report
a rural state code (code beginning with 999) as
the Core Based Statistical Area (CBSA) code for
the beneficiary‟s residence will receive the
additional 3 percent payment. The CBSA code is
reported associated with value code „61‟ on
home health claims. CMS is working to
expeditiously implement the home health rural addon
provision.
Section 3122 of the PPACA re-institutes
reasonable cost payment for clinical lab tests
performed by hospitals with fewer than 50 beds
in qualified rural areas as part of their outpatient
services for cost reporting periods beginning on
or after July 1, 2010, through June 30, 2011. This
could affect services performed as late as June
30, 2012.
If you are a hospital that qualifies under Section
3122, you do not need to take any action. You
will receive reasonable cost reimbursement for
an entire year, starting with your cost reporting
period beginning on or after July 1, 2010.
Ceilly Robl
Phone: (303) 844-4861
E-mail your questions and comments to us at:
PulseofDenverRO@cms.hhs.gov
Extension of Outpatient
Hold-Harmless Provision
PPACA extends the outpatient hold-harmless
provision, effective for dates of service on and after
January 1, 2010, through December 31, 2010, to
rural hospitals with 100 or fewer beds and to all sole
community hospitals and essential access
community hospitals, regardless of bed size.
Reasonable Cost Payments
for Lab Tests in Some Rural
Hospitals
The Patient Protection and Affordable Care Act
Click here to read the entire text of the legislation signed into law
by President Obama on March 23, 2010.
The Pulse of CMS Page 3
Billing for the Technical
Component of Pathology
Services
Section 3104 extends the moratorium that allows
independent laboratories to bill for the technical
component (TC) of physician pathology services
furnished to patients in hospitals, effective for claims
with dates of service on and after January 1, 2010,
through December 31, 2010.
In the final physician fee schedule regulation
published in the Federal Register on November 2,
1999, CMS stated that it would implement a policy to
pay only the hospital for the TC of physician
pathology services furnished to hospital patients. At
the request of industry, to allow independent
laboratories and hospitals sufficient time to negotiate
arrangements, the implementation of this rule was
administratively delayed. Subsequent legislation
formalized a moratorium on the implementation of
the rule.
Although the previous extension of the moratorium
expired at the end of 2009, Section 3104 of the
PPACA restored the moratorium retroactive to
January 1, 2010. Therefore, independent
laboratories may now submit claims to Medicare for
the TC of physician pathology services furnished to
patients of a hospital, regardless of the beneficiary's
hospitalization status (inpatient or outpatient) on the
date that the service was performed. This policy is
effective for claims with dates of service on or after
January 1, 2010, through December 31, 2010. If an
independent laboratory previously submitted a claim
for services covered by this provision and the claim
was denied, the laboratory may contact its Medicare
contractor for further instructions.
PPACA Sections 3401 and 3137 contain a number of
provisions affecting institutional providers. The 3401
sections discussed below are effective April 1, 2010,
while Section 3137(a) has October 1, 2009, and April
1, 2010 effective dates. CMS is working to
expeditiously implement these important
provisions of PPACA. Providers will begin seeing
payments under these provision in the late
April/early May time frame.
Inpatient Acute Hospitals (Section 3401(a))
Section 3401(a) of PPACA imposes a 0.25
percentage point reduction to the Inpatient
Prospective Payment System (IPPS) hospital‟s
market basket for fiscal year (FY) 2010, effective for
discharges on or after April 1, 2010. The
reduction to the market basket will affect IPPS
rates for discharges occurring on or after April 1,
2010, through September 30, 2010.
Long-Term Care Hospitals (Section 3401(c))
Section 3401(c) of PPACA imposes a 0.25
percentage point reduction to the Long Term Care
Hospital‟s (LTCH) market basket for FY 2010,
effective for discharges on or after April 1, 2010.
The reduction to the market basket will affect
LTCH rates for discharges occurring on or after
April 1, 2010, through September 30, 2010.
Inpatient Rehabilitation Facilities (Section
3401(d))
Section 3401(d) of PPACA imposes a 0.25
percentage point reduction to the Inpatient
Rehabilitation Facility market basket for FY 2010,
effective for discharges on or after April 1,
2010. The reduction is also resulting in changes
to the standard payment conversion factor,
payment rates, and the outlier threshold amount.
Extension of Section 508 Hospital
Reclassifications (Sections 3137(a) and 10317)
Sections 3137(a) and 10317 extend section 508 and
special exception hospital reclassifications from
October 1, 2009, through September 30,
2010. Effective April 1, 2010, section 3137(a) and
10317 also require removing section 508 and special
exception wage data from the calculation of the
reclassified wage index if doing so raises the
reclassified wage index. All hospitals affected by
sections 3137(a) and 10317 will be assigned an
individual special wage index effective April 1,
2010. If the section 508 or special exception
hospital‟s wage index applicable for the period
beginning on October 1, 2009, and ending on March
31, 2010, is lower than for the period beginning on
April 1, 2010, and ending on September 30, 2010,
the hospital will be paid an additional amount that
reflects the difference between the wage indices. The
provision applies to both inpatient and outpatient
hospital payments.
PPACA Provisions Impacting Institutional
Medicare Providers
Exceptions Process for Therapy Caps Extended
Through 2010
Section 3103 extends the exceptions process for
outpatient therapy caps. Outpatient therapy service
providers may continue to submit claims with the „KX‟
modifier, when an exception is appropriate, for
services furnished on or after January 1, 2010,
through December 31, 2010.
The therapy caps are determined on a calendar
year basis, so all patients began a new cap year
on January 1, 2010. For physical therapy and
speech language pathology services combined,
the limit on incurred expenses is $1,860. For
occupational therapy services, the limit is
$1,860. Deductible and coinsurance amounts
applied to therapy services count toward the
amount accrued before a cap is reached.
1600 Broadway
Suite 700
Denver, CO 80202
Phone: 303-844-2111
Fax: 303-844-3753
Email: PulseofDenverRO@cms.hhs.gov
Denver Regional Office:
The Pulse of CMS Page 4
Information Disclaimer:
The information provided in this newsletter is intended only to be general summary information to the Region VIII
provider community. It is not intended to take the place of either the written law or regulations.
Links to Other Resources:
Our newsletter may link to other federal agencies. You are subject to those sites‟ privacy policies. Reference in this
newsletter to any specific commercial products, process, service, manufacturer, or company does not constitute its
endorsement or recommendation by the U.S. government, HHS or CMS. HHS or CMS is not responsible for the
contents of any “off-site” resource identified.
Physician Supervision
Requirements in CAHs
Relaxed
On March 23, 2010, CMS announced its decision to
cover facial injections for Medicare beneficiaries who
experience symptoms of depression due to the
stigmatizing appearance of severely hollowed cheeks
resulting from the drug treatment for Human
Immunodeficiency Virus (HIV). This decision is
effective immediately.
Facial lipodystrophy (LDS) is a localized loss of fat
from the face, causing an excessively thin
appearance in the cheeks. In some cases, facial LDS
may be a side effect of certain kinds of medications
(antiretroviral therapies) that individuals receive as
part of an HIV infection treatment regimen.
The facial LDS can leave people living with HIV
looking gaunt and seriously ill, which may stigmatize
them as part of their HIV-infection status. Individuals
who take these medications and experience facial
LDS side effects may suffer psychological effects
related to a negative self-image. These effects may
lead people living with HIV to discontinue their
antiretroviral therapies. The new decision allows for
treatment of individuals who experience symptoms of
depression due to the appearance changes from
facial LDS.
The injections included in this coverage decision are
“fillers” that have been approved by the U.S. Food &
Drug Administration to be injected under the skin in
the face to help fill out its appearance specifically for
treatment of facial LDS. Data show that these
injections can improve patient self-image, relieve
symptoms of depression, and may lead to improved
compliance with anti-HIV treatment.
“Today‟s decision marks an important milestone in
Medicare‟s coverage for HIV-infection therapies,”
said Barry M. Straube, M.D., CMS Chief Medical
Officer and Director of the Agency‟s Office of Clinical
Standards & Quality. “Helping people living with HIV
improve their self-image and comply with anti-HIV
treatment can lead to better quality of life and,
ultimately, improve the quality of care that
beneficiaries receive.”
The final decision is posted on the CMS Website.
.
Medicare Expands Coverage for Treating Facial
Lipodystrophy Syndrome in People Living with HIV
In the 2010 hospital outpatient prospective payment
system and ambulatory surgical center rule (CMS-
1413-FC), CMS detailed physician supervision
requirements for outpatient therapeutic services by
hospitals and critical access hospitals (CAHs). The
physician supervision requirements for outpatient
therapeutic services (excluding physical therapy,
occupational therapy, and speech pathology, as well
as programs for cardiac rehab, intensive cardiac
rehab, and pulmonary rehab services) prompted
some concern among CAHs, many of which do not
have physicians or mid-level practitioners onsite 24
hours a day, seven days a week.
Accordingly, in a March 15, 2010, posting on the
CAH center of the CMS website, CMS indicated it will
instruct all of its Medicare contractors not to evaluate
or enforce the supervision requirements for
therapeutic services provided to outpatients in CAHs
from January 1 through December 31, 2010. CMS
plans to revisit the issue of supervision for
therapeutic services provided to hospital outpatients
in CAHs through the annual rulemaking cycle in
2011. CMS continues to expect CAHs to fulfill all
other Medicare program requirements when
providing services to Medicare beneficiaries and
when billing Medicare for those services. CMS
continues to emphasize quality and safety for
services provided to all patients in CAHs.
CMS recently awarded new banking contracts to U.S.
Bank and JP Morgan Chase. Medicare providers do
not have to take any action. However, providers
should be aware that the Medicare payments may be
made by a different bank than in the past because of
these new banking contractors.
The following Medicare claims processing
contractors will remain with JP Morgan
Chase: Cahaba Government Benefit Administrators,
Pinnacle Business Solutions, First Coast Service
Options, Palmetto GBA (except for A/B MAC
Jurisdiction 1), and Wisconsin Physician
Service. Providers who bill to these contractors will
not experience any change.
The following Medicare claims processing
contractors will transition to JP Morgan Chase on
June 1, 2010: Palmetto A/B MAC Jurisdiction 1 and
Trailblazer.
The following contractors will transition to U.S. Bank
on June 1, 2010, CIGNA Government Services,
Highmark Medicare Services, National Government
Services, NHIC and Noridian Administrative
Services.
CMS Awards Banking Contracts to U.S. Bank and
JP Morgan Chase