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Below you will find a listing of current Centers for Medicare & Medicaid Services (CMS) program information (transmittals, corrections/changes to existing Medicare guidelines, etc.) and general updates to this Web site.

Note: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material which is copyrighted by the American Medical Association (AMA). 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 (you will be linked back to here).

2013 - May | April | March | February | January

2012 - December | November | October | September | August | July | June | May | April | March | February | January

2011 - December | November | October | September | August | July | June | May | April | March | February | January

May

16 May 2013

09 May 2013

02 May 2013

April

25 April 2013

22 April 2013

  • New and Revised Sequestration Questions and Answers
    On April 8, 2013, the Centers for Medicare & Medicaid Services (CMS) issued a Q & A to explain the effect of the payment reduction for durable medical equipment (DME) capped rental claims. It has come to CMS’ attention that this Q & A requires additional clarification and issued the following Q & A as a replacement:
    Question: If a Durable Medical Equipment capped rental period started before April 1, 2013, are the rental payments for months after April 1, 2013, subject to the 2% reduction?
    Answer: Any claims for rental payments with a “FROM” date of service on or after April 1, 2013, will be subject to the 2% reduction, regardless of when the rental period began. For example, if a capped rental wheelchair was provided in February 2013, the monthly rental payment for May 2013 would be subject to the 2% sequestration reduction. The initial and subsequent monthly rental payments billed with a “FROM” date of service beginning on or prior to March 31, 2013 would not be affected by the 2% reduction.

    In addition, CMS issued the following new Qs & As as well as the revised Q & A above:

    Question: How long is the 2% reduction to Medicare fee-for-service claim payments in effect?
    Answer: The law specifies that the 2% reduction to Medicare fee-for-service payments resulting from the sequestration order that the President was required to issue on March 1, 2013, applies to all payments for services furnished in the one-year period after the reductions begin. For Medicare, the reductions begin on the first day of the first month after the order is issued, meaning they began on April 1, 2013. Accordingly, this sequestration order covers all payments for services with dates of service or dates of discharge (or a start date for rental equipment or multi-day supplies) April 1, 2013, through March 31, 2014.
    Question: Are drugs excluded from the 2% reduction?
    Answer: No. All fee-for-service Medicare claim payments are subject to the 2% reduction. There are no exemptions provided in the law for drugs or any other health care item or service provided under the fee-for-service program.

18 April 2013

11 April 2013

09 April 2013

  • Additional Question and Answer Related to Sequestration

    Question: If a Durable Medical Equipment capped rental period started before April 1, 2013, are the rental payments for months after April 1, 2013, subject to the 2% reduction?

    Answer: Any claims for rental payments with a “FROM” date of service on or after April 1, 2013, will be subject to the 2% reduction, regardless of when the rental period began. For example, if a capped rental wheelchair was provided in February 2013, the monthly rental payment for May 2013 would be subject to the 2% sequestration reduction. The initial monthly rental payment for February 2013 would not be affected by the 2% reduction.

04 April 2013

March

28 March 2013

27 March 2013

  • Additional Questions and Answers Related to Sequestration
    (TDL 13276)


    Question: How is the 2% payment reduction under sequestration identified on the electronic remittance advice (ERA) and the standard paper remittance (SPR)?
    Answer: Claim adjustment reason code (CARC) 223 is used to report the sequestration reduction on the ERA and SPR.

    Question: What is the verbiage for CARC 223?
    Answer: “Adjustment code for mandated Federal, State or local law/regulation that is not already covered by another code and is mandated before a new code can be created.”

    Question: Will the 2% reduction be reported on the remittance advice in a separate field?
    Answer: For institutional Part A claims, the adjustment is reported on the remittance advice at the claim level. For Part B physician/practitioner, supplier, and institutional provider outpatient claims, the adjustment is reported at the line level.

    Question: How will the payments be calculated on the claims?
    Answer: The reduction is taken from the calculated payment amount, after the approved amount is determined and the deductible and coinsurance are applied.

    Example: A provider bills a service with an approved amount of $100.00, and $50.00 is applied to the deductible. A balance of $50.00 remains. We normally would pay 80% of the approved amount after the deductible is met, which is $40.00 ($50.00 x 80% = $40.00). The patient is responsible for the remaining 20% coinsurance amount of $10.00 ($50.00 - $40.00 = $10.00). However, due to the sequestration reduction, 2% of the $40.00 calculated payment amount is not paid, resulting in a payment of $39.20 instead of $40.00 ($40.00 x 2% = $0.80).

    Question: How are unassigned claims affected by the 2% reduction under sequestration?
    Answer: Though beneficiary payments toward deductibles and coinsurance are not subject to the 2% payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the 2% reduction. The non-participating physician who bills on an unassigned basis collects his/her full payment from the beneficiary, and Medicare reimburses the beneficiary the Medicare portion (e.g., 80% of the reduced fee schedule amount. NOTE: The “reduced fee schedule” refers to the fact that Medicare’s approved amount for claims from non-participating physicians/practitioners is 95% of the full fee schedule amount). This reimbursed amount to the beneficiary would be subject to the 2% sequester reduction just like payments to physicians on assigned claims. Both are claims payments, just to different parties. If the Limiting Charge applies to the service rendered, physicians/practitioners cannot collect more than the Limiting Charge amount from the beneficiary.

    Example: A non-participating provider bills an unassigned claim for a service with a Limiting Charge of $109.25. The beneficiary remains responsible to the provider for this full amount. However, sequestration affects how much Medicare reimburses the beneficiary. The non-participating fee schedule approved amount is $95.00, and $50.00 is applied to the deductible. A balance of $45.00 remains. Medicare normally would reimburse the beneficiary for 80% of the approved amount after the deductible is met, which is $36.00 ($45.00 x 80% = $36.00). However, due to the sequestration reduction, 2% of the $36.00 calculated payment amount is not paid to the beneficiary, resulting in a payment of $35.28 instead of $36.00 ($36.00 x 2% = $0.72).

    We encourage physicians, practitioners, and suppliers who bill unassigned claims to discuss with their Medicare patients the impact of the sequestration reductions to Medicare payments.

    Question: Is this reduction based on the date of service or date of receipt?
    Answer: In general, Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment. Claims for durable medical equipment (DME), prosthetics, orthotics, and supplies, including claims under the DME Competitive Bidding Program, will be reduced by 2 percent based upon whether the date-of-service, or the start date for rental equipment or multi-day supplies, is on or after April 1, 2013.

21 March 2013

15 March 2013

14 March 2013

12 March 2013

07 March 2013

01 March 2013

February

28 February 2013

26 February 2013

  • Therapy Cap Manual Medical Review Instructions for 2012 and 2013 – ACTION
    TDL 13215

    Section 603 of the American Taxpayer Relief Act of 2012 (ATRA) contains a number of Medicare provisions affecting the outpatient therapy caps and mandatory manual medical review (MR) thresholds that became effective January 1, 2013.
    • Contractors shall continue to review therapy claims that did not go through the pre-approval process for dates of service October 1, 2012 through December 31, 2012.
    • Until CMS provides further instructions, all therapy claims that are suspended for manual medical review in 2013, above the $3,700 threshold, will be subject to prepayment medical review.

21 February 2013

14 February 2013

07 February 2013

January

31 January 2013

24 January 2013

22 January 2013

17 January 2013

11 January 2013

10 January 2013

04 January 2013

  • Extension of the 2013 Annual Participation Enrollment Program
    TDL 13149

    The Centers for Medicare & Medicaid Services (CMS) is extending the 2013 Annual Participation Enrollment Program. The participation enrollment period will now end February 15, 2013, instead of December 31, 2012.

03 January 2013

December

27 December 2012

20 December 2012

13 December 2012

06 December 2012

November

29 November 2012

20 November 2012

15 November 2012

14 November 2012

  • To Our J14 Medical Community:
    (Change Request 8055)

    The Medicare Physician Fee Schedule Database (MPFSDB) and the Anesthesia files are available on our web site. Please go to http://www.medicarenhic.com/ne_prov/fee_sched.shtml to view the file for your Area. Any future updates released by CMS will be posted as soon as they are available.
    The Annual Participation Open Enrollment Period also has begun. To view the pertinent documents, please go to http://www.medicarenhic.com/ne_prov/fee_sched.shtml where you will find the CMS Announcement and the Medicare Participating Physician or Supplier Agreement (Form CMS 460). The mailing address is listed immediately below the forms on the same web page.
    Reminder: Any participating health professional who is not changing their participation status does not need to take any action during the Annual Open Enrollment Period.

8 November 2012

1 November 2012

October

29 October 2012

  • 2013 Fee Schedule / Open Enrollment Period
    (Change Request 8055; Internet Only Manual (IOM), Pub 100-04, Chapter 1, 30.3.12.1)

    NHIC, Corp. reminds our medical community that the upcoming Participation enrollment period documents and the upcoming Medicare Physician Fee Schedule (MPFS) and the Anesthesia Conversion Factor(s) will be published on the our web site after the physician fee schedule regulation is put on display. Once the rule is on display, you may go to http://www.medicarenhic.com/ne_prov/fee_sched.shtml for the related 2013 information.

18 October 2012

11 October 2012

04 October 2012

September

27 September 2012

26 September 2012

20 September 2012

13 September 2012

07 September 2012

06 September 2012

August

30 August 2012

23 August 2012

16 August 2012

13 August 2012

  • CMS Fraud Prevention Training Modules for Providers
    TDL 12472

    In June 2012, the Centers for Medicare & Medicaid Services produced two fraud prevention training modules that are currently available on the Medscape website (see below). These modules provide key information to health care practitioners and professionals on how they can assist CMS in preventing fraud and abuse, as well as highlight CMS’ efforts to fight fraud and abuse and explain how health care professionals can be part of these efforts.
    The first module, “Reducing Medicare and Medicaid Fraud and Abuse: Protecting Practices and Patients, can be found here: http://www.medscape.org/viewarticle/764496.
    The second module, “How CMS Is Fighting Fraud: Major Program Integrity Initiatives,” can be found here: http://www.medscape.org/viewarticle/764791.

    A total of 1.25 hours of continuing medical education (CME) credit can be earned for any Medscape user registered as a doctor or health care professional. Medscape accounts are free, and users do not have to be health care professionals to register for them. Registration is on the landing page of www.medscape.com. Instructions for Accessing the Medscape Modules
    • Step 1: Access the Web site: www.medscape.org. Medscape accounts are free of charge.
    • Step 2: Registration is on the upper right hand corner of the home page of www.medscape.org next to the log in field.
    • Step 3: To access the modules, first enter your membership log in information.

09 August 2012

July

26 July 2012

18 July 2012

05 July 2012

June

28 June 2012

21 June 2012

14 June 2012

04 June 2012

May

31 May 2012

29 May 2012

24 May 2012

10 May 2012

03 May 2012

April

26 April 2012

12 April 2012

05 April 2012

March

29 March 2012

22 March 2012

15 March 2012

13 March 2012

08 March 2012

  • The Centralized Billing for Flu and Pneumococcal Vaccination Annual Notice has been published. (IOM, 100-04, Chapter 18)
  • Common Working File (CWF) Northeast, Pacific and South Hosts Dark Day on Saturday, March 24, 2012
    (TDL-12251)

    On Saturday, March 24, 2012, the CWF Northeast, Pacific and South Hosts will be conducting a history purge. Due to the anticipated duration of this activity and to ensure the completion of weekly processing and scheduled data center maintenance, there will be a CWF Dark Day at the CWF Northeast, Pacific and South Hosts only on that Saturday. This means there will be no access to the Health Insurance Master Record (HIMR) query, which is usually available until noon on Saturdays.
    All files received from satellites for Friday’s cycle (March 23, 2012) will be completed prior to bringing CWF production down. If, for any reason, satellite files are received late Saturday morning, they will be processed by CWF after the history purge has been completed.

01 March 2012

February

16 February 2012

09 February 2012

02 February 2012

January

26 January 2012

19 January 2012

12 January 2012

05 January 2012

  • Quarterly Provider Update (QPU)
    (IOM Pub 100-09-Chapter 6 Section 50.2.4.3)

    The Quarterly Provider Update (QPU) is a listing of the regulations and program instructions issued by CMS that impact Medicare providers. The QPU is maintained by CMS and available to providers through the CMS Web site.
    Providers may elect to join a CMS electronic mailing list, to be notified periodically, of additions to the QPU. CMS publishes this Update at the beginning of each quarter to inform the public about the following:
    • Regulations and major policies currently under development during this quarter.
    • Regulations and major policies completed or cancelled.
    • New/Revised manual instructions
    The page may be found at: http://www.cms.hhs.gov/QuarterlyProviderUpdates/
    Visit the QPU What’s New page at https://www.cms.gov/QuarterlyProviderUpdates/02_Spotlight.asp

December

28 December 2011

21 December 2011

15 December 2011

08 December 2011

01 December 2011

November

29 November 2011

22 November 2011

  • Change Request 7177 has been rescinded and is replaced by Change Request 7681.
  • Attention Providers:
    (Per Change Request 7573)

    We encourage you to visit the Medicare Learning Network (http://www.cms.gov/MLNGenInfo/ )--the place for official CMS Medicare fee-for-service provider educational information. There you can find one of our most popular products, MLN Matters national provider education articles. These articles help you understand new or changed Medicare policy and how those changes affect you. A full array of other educational products (including Web-based training courses, hard copy and downloadable publications, and CD-ROMs) are also available and can be accessed at: http://www.cms.gov/MLNProducts/ . You can also find other important physician Web sites by visiting the Physician Center Web page at: http://www.cms.gov/center/physician.asp.
  • To Our J14 Medical Community:
    (Change Requests 7573 and 7412)

    The Medicare Physician Fee Schedule Database (MPFSDB) and the Anesthesia files are available on our web site. Please go to http://www.medicarenhic.com/ne_prov/fee_sched.shtml to view the file for your Area and a short message from the Centers for Medicare & Medicaid Services (CMS).
    Any future updates released by CMS will be posted as soon as they are available.
    The Annual Participation Open Enrollment Period also has begun. To view the pertinent documents, please go to http://www.medicarenhic.com/ne_prov/fee_sched.shtml where you will find the CMS Announcement and the Medicare Participating Physician or Supplier Agreement (Form CMS 460). The mailing address is listed immediately below the forms on the same web page.
    Reminder: Any participating health professional who is not changing their participation status does not need to take any action during the Annual Open Enrollment Period.

17 November 2011

09 November 2011

03 November 2011

October

27 October 2011

20 October 2011

06 October 2011

September

29 September 2011

22 September 2011

15 September 2011

08 September 2011

01 September 2011

August

25 August 2011

18 August 2011

11 August 2011

04 August 2011

July

28 July 2011

22 July 2011

  • Common Working File Great Lakes and Northeast Hosts Dark Day on Saturday, July 23, 2011
    CMS Technical Direction Letter (TDL)-11410

    On Saturday, July 23, 2011, the Common Working File (CWF) Great Lakes and Northeast Hosts will be conducting a history purge. Due to the anticipated duration of this activity and to ensure the completion of weekly processing and scheduled data center maintenance, there will be a CWF dark day at the CWF Great Lakes and Northeast Hosts only on that Saturday. This means there will be no access to the Health Insurance Master Record (HIMR) query, which is usually available until noon on Saturdays.
    All files received from satellites for Friday's cycle (July 22, 2011) will be completed prior to bringing CWF production down. If, for any reason, satellite files are received late Saturday morning, they will be processed by CWF after the history purge has been completed.

21 July 2011

07 July 2011

June

30 June 2011

23 June 2011

16 June 2011

09 June 2011

May

26 May 2011

19 May 2011

12 May 2011

6 May 2011

  • JSM/TDL 11264
    CMS Message 201105-10
    Medicare Part B Average Sales Price - Payments for Wilate and Flulaval

    For the April 2011 Average Sales Price quarterly update, CMS is not publishing a payment limit for HCPCS code J7184 [Injection, Von Willebrand Factor Complex (Human), Wilate, Per 100 iu VWF:RCO] for claims with dates of service between Friday, April 1 and Thursday, June 30, 2011. A price for Wilate can be found on the “April 2011 ASP Not Otherwise Classified (NOC)” pricing file available on the CMS website. Additionally, as per updated CR #7234, CMS has updated the price for Q2036 (Flulaval vacc, 3 yrs & >, im) to $8.784 for the April 2011 ASP quarterly update. This updated price is effective for claims with dates of service on or after Friday, October 1, 2010. The revised price has been added to the October 2010 and January 2011 ASP pricing files. These pricing files can be found on the CMS website at http://www.CMS.gov/McrPartBDrugAvgSalesPrice.

5 May 2011

April

28 April 2011

21 April 2011

14 April 2011

  • Change Request 7177 has been rescinded and is replaced by Change Request 7681.

07 April 2011

March

31 March 2011

24 March 2011

17 March 2011

10 March 2011

03 March 2011

February

24 February 2011

10 February 2011

03 February 2011

January

27 January 2011

20 January 2011

13 January 2011

06 January 2011

04 January 2011

  • Face-to-Face Encounter Home Health Certification Requirement
    (JSM/TDL-11111)
    Section 6407 of the Affordable Care Act of 2010 established a physician face-to-face encounter requirement for certification of eligibility for Medicare home health services. The law requires that the certifying physician must document that he or she, or a non-physician practitioner (NPP) working with the physician, has seen the patient.
    In the Home Health Prospective Payment System Rate Update for Calendar Year (CY) 2011, the Centers for Medicare & Medicaid Services (CMS) finalized its implementation approach for this law. Pursuant to 42 C.F.R. § 424.22(a)(1)(v) (75 Fed. Reg. 70464, November 17, 2010), the face-to-face encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care. The regulation also states that the certifying physician must document the encounter as part of the certification itself or as a signed addendum to it. The documentation must include the date when the encounter occurred and a brief narrative which describes how the clinical findings of the encounter support the patient’s homebound status and need for skilled services. The rule requires such documentation be present on certifications for patients with starts of care on or after January 1, 2011.
    Although many home health agencies and physicians are aware of and are able to comply with this policy, CMS is concerned that some home health agencies and physicians may need additional time to establish operational protocols necessary to comply with this new law. As such, CMS expects that during the first quarter of CY 2011, home health agencies and physicians who order home health services will collaborate and establish internal processes to ensure compliance. Beginning with the second quarter of CY2011, home health agencies will have fully established such internal processes and CMS will expect appropriate documentation of the encounter.
    CMS will continue to address industry questions concerning the new requirement, and will update information on our Web site at http://www.cms.gov/center/hha.asp. We will also use other channels we have to communicate with providers to ensure information is widely distributed.
  • Hospice Face-to-Face Encounter Requirement
    (JSM/TDL-11112)
    Section 3131(b) of the Affordable Care Act of 2010 requires a hospice physician or nurse practitioner (NP) to have a face-to-face encounter with every hospice patient prior to the patient’s 180th- day recertification, and each subsequent recertification. The provision applies to recertifications on and after January 1, 2011.
    In the Home Health Prospective Payment System Rate Update for Calendar Year (CY) 2011, the Centers for Medicare & Medicaid Services (CMS) finalized its implementation approach for this hospice provision. The final rule, codified at 42 C.F.R. 418.22(a)(4) (75 Fed. Reg. 70463, November 17, 2010) states that the encounter must occur no more than 30 calendar days prior to the start of the hospice patient’s third benefit period. The regulation requires that the hospice physician or nurse practitioner attest that the encounter occurred, and the recertifying physician must include a narrative which describes how the clinical findings of the encounter support the patient’s terminal prognosis of 6 months or less. Both the narrative and the attestation must be part of, or an addendum to, the recertification.
    Although many hospices are aware of and are able to comply with this policy, CMS is concerned that some hospices may need additional time to establish operational protocols necessary to comply with this new law. As such, CMS expects that during the first quarter of CY 2011, hospices will establish internal processes to ensure compliance. Beginning with the second quarter of CY 2011, hospices will have fully established such internal processes and CMS will expect appropriate documentation of the encounter.
    CMS will address industry questions concerning the new requirement on our Web site at http://www.cms.gov/center/hospice.asp. We will also use other channels we have to communicate with providers to ensure information is widely distributed.

 

05/16/2013

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