CMS Updates. CMS Releases FY 2015 Proposed IPPS. Protecting Access to Medicare Act of 2014 (H.R. 4302)

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1 CMS, Medicare Administrative Contractor, and Recovery Auditor Activity Updates April 2014

2 CMS Updates CMS Releases FY 2015 Proposed IPPS On May 1, 2014, CMS released the FY 2015 Inpatient Prospective Payment System (IPPS) proposed rule. In the proposed rule, CMS is seeking public comment on an alternative payment methodology for short inpatient hospital stays. CMS is also continuing to seek suggestions of other services and procedures (other than Inpatient-Only and Mechanical Ventilation) that would justify inpatient admission and Part A payment absent an expectation of care spanning at least 2 midnights. In the proposed rule, CMS is proposing to amend the regulations governing the timing of the 96-hour certification requirement at (b) such that physician certification is required no later than 1 day before the date on which the claim for payment for the inpatient CAH service is submitted and not prior to discharge. Similarly, CMS is proposing to amend (d)(5) to allow CAHs to perform a delayed certification after discharge. CMS seeks public comment on these proposed changes. Comments are due no later than 5:00 PM on June 30, Protecting Access to Medicare Act of 2014 (H.R. 4302) The Protecting Access to Medicare Act of 2014 was passed by the Senate on March 31, 2014 and signed into law by President Obama on April 1, The passage of H.R marked the 17th time since 2003 that Congress has acted to temporarily delay cuts to doctor reimbursements under Medicare. This act defers until April 1, 2015 the SGR (sustainable growth rate) mandated 24% reimbursement cut required by the Balanced Budget Act of 1997 for physicians treating Medicare patients. This law also delays national implementation of ICD-10 and CMS has yet to provide clarity for how hospitals, doctors, and insurance companies should move forward. Section 111(a) of the Protecting Access to Medicare Act of 2014 allows for the Secretary of Health and Human Services to discretionarily extend the Probe and Educate program for an additional 6 months (it is currently slated to run through October 31, 2014). Section 111(a) states that Recovery Audit contractors shall not conduct patient status reviews (0-1 day stays as described in the Selecting Hospital Claims for Patient Status Reviews notice) on a post-payment review basis for inpatient claims with dates of admission October 1, 2013, through March 31, 2015, unless there is evidence of systematic gaming, fraud, abuse, or delays in the provision of care by a provider of services.

3 Medicare Administrative Contractor by State Cahaba CGS FCSO NGS NORIDIAN NOVITAS PALMETTO WPS J10 JI J9 J6 JF JH J11 J5 Alabama Kentucky Florida Minnesota Alaska New Mexico North Iowa Carolina Georgia Ohio US Wisconsin Arizona Colorado South Kansas Virgin Islands Carolina Tennessee Puerto Illinois Idaho Texas Virginia Missouri Rico JK Montana Oklahoma West Nebraska Virginia New York North Arkansas J8 Dakota Connecticut Oregon Louisiana Michigan Maine South Mississippi Indiana Dakota Rhode Island Utah JL Vermont Washington Pennsylvania New Wyoming Maryland Hampshire Massachusetts JE New Jersey California Delaware Hawaii Nevada American Samoa Guam Northern Mariana Islands

4 Medicare Administrative Contractor Updates Cahaba Government Benefit Administrators Cahaba GBA s Current Prepayment Medical Review Log for Part A*: Inpatient Rehabilitation Facility A0801-A0806 and A0701-A0703 Inpatient Rehab A2001-A2004 Condition Code 07-The patient has elected hospice care but the provider is not treating the terminal condition, and is, therefore, requesting regular Medicare payment. Final Rule CMS 1599-F, 2 Midnight Rule Inpatient Admissions *Cahaba GBA last updated this list on April 3, This is not an exhaustive list; the complete list can be found at Cahaba GBA website: No new contractor specific information at this time. CGS CGS Website: First Coast Service Options On February 14, 2014, the Centers for Medicare & Medicaid Services (CMS) selected First Coast Service Options Inc. (First Coast) to continue to be the Medicare administrative contractor (MAC) for Florida, Puerto Rico and U.S. Virgin Islands. As a result of the transition to the new contract, effective June 16, 2014, jurisdiction 9 (J9) will be referred to as jurisdiction (JN). For the full article about FCSO s contract award, follow this link: FCSO Contract Award Note: As of October 1, 2013, FCSO has removed every DRG from prepayment review. The complete details of FCSO inpatient DRGs subject to prepayment medical review, including the CERT and FCSO error rate findings for each issue, can be found at: FCSO website:

5 No new contractor specific information at this time. National Government Services National Government Services website: Noridian Healthcare Solutions These service-specific prepayment reviews are currently in effect in Noridian Jurisdiction F: DRG Circulatory disorders except AMI, w card cath w/o MCC (Targeted Review) o States Affected: WA, AK, ID, OR These service-specific prepayment reviews are currently in effect in Noridian Jurisdiction E: DRG Spinal Fusion except Cervical without Major Complications or Comorbidities (MCC) o States Affected: CA, NV These service-specific prepayment reviews are state specific. The list of affected states, along with interim findings can be found at (JF) and (JE) Noridian Healthcare Solutions: (JF) and (JE) Novitas Service Wide (Widespread) Edits (Jurisdiction H): Novitas Solutions, Inc. PLEASE NOTE: THE FOLLOWING EDITS HAVE ALL BEEN SUSPENDED DRG 227: Cardiac Defibrillator Implant without cardiac cath without Major Complication/Co morbidity (MCC) with length of stay < 3 days DRG 243: Permanent Cardiac Pacemaker Implant with CC (Complications/Comorbidity) with length of stay < 3 days

6 DRG 244: Permanent Cardiac Pacemaker Implant without Complications/Comorbidity (CC) / Major Complication/Co morbidity (MCC) with length of stay < 3 days DRG 251: Percutaneous Cardiovascular Procedure without Coronary Artery Stent without Major Complication/Comorbidity (MCC) with length of stay < 3 days DRG 287: Circulatory Disorders except AMI with Cardiac Cath without Major Complication/Comorbidity (MCC) with length of stay < 3 days DRG 470: Major joint replacement or reattachment of lower extremity without MCC with length of stay < 3 days DRG 673: Other Kidney and Urinary Tract Procedures with Major Complication/Comorbidity (MCC) with length of stay < 3 days DRG 714: Transurethral Prostatectomy without Complication/Comorbidity(CC) / Major Complication/Comorbidity (MCC) with length of stay < 3 days Novitas Service Wide (Widespread) Edits (Jurisdiction L): PLEASE NOTE: THE FOLLOWING EDITS HAVE ALL BEEN SUSPENDED DRG 227: Cardiac Defibrillator Implant without cardiac cath without Major Complication/Co morbidity (MCC) with length of stay < 3 days DRG 243: Permanent Cardiac Pacemaker Implant with CC (Complications/Comorbidity) with length of stay < 3 days DRG 244: Permanent Cardiac Pacemaker Implant without Complications/Comorbidity (CC) / Major Complication/Co morbidity (MCC) with length of stay < 3 days DRG 292: Heart Failure and Shock with CC with length of stay < 3 days DRG 313: Chest Pain with length of stay < 3 days DRG 392: Esophagitis, Gastroenteritis and Miscellaneous Digestive D/O w/o MCC with length of stay < 3 days DRG 470: Major joint replacement or reattachment of lower extremity without MCC with length of stay < 3 days DRG 551: Medical back problems with MCC with length of stay < 3 days DRG 552: Medical back problems without MCC with length of stay < 3 days DRG 714: Transurethral prostatectomy without CC/MCC with length of stay < 3 days Novitas website: No new contractor specific information at this time. Palmetto Government Benefit Administrators Palmetto GBA website:

7 Wisconsin Physicians Service Wisconsin Physician Services (WPS) has indicated a number of service-specific (prepay) edits. WPS current prepay edits include the following: 48 hour Observation Reason Code: E51#L High Dollar Claims Reason Code: 50BMM Inpatient Rehabilitation Facility (IRF) Reason Code: 50IRF Long Term Acute Care Hospital (LTCH) Reason Code: 5LTCH Short Term Acute Care Hospital (STCH) Reason Code: 5NERV, 50ENT, 5 RESP, 5CIRC, 5DIGS, 5PANC, 5MUSC, 5SKIN, 5GLND, 5KIDN, 5HEAL The complete list of WPS current service-specific prepay edits can be found at: WPS website: (J5 MAC Part A) and (J8 MAC Part A).

8 Recovery Auditor Updates The Recovery Auditor Prepayment Review Demonstration began in August The demonstration is applicable to seven HEAT states (California, Florida, Illinois, Louisiana, Michigan, New York, and Texas) and four states (Missouri, North Carolina, Ohio, and Pennsylvania) The following information was recently posted on the Recovery Auditor Program Recent Updates page on the CMS website: May 1, 2014 The following information is intended to notify providers of current Recovery Auditors activities after June 1, As noted in previous updates, the last day that Recovery Auditors may send claim adjustment files to the Medicare Administrative Contractors (MAC) is June 1, As of June 2, 2014, only claim closure files may be sent to the MACs, by the Recovery Auditor. Because no additional reviews will occur under the current contracts, current Recovery Auditors will not be required to update the New Issue ( Approved Issue ) portion of their websites, as of June 2, However, Recovery Auditors shall continue to update the Claims Status portion of their provider portal, in a timely manner, until further notice. Recovery Auditors shall complete all Discussion Periods that are underway as of June 1, Recovery Auditors shall continue to accept new Discussion Period requests until June 30, All Discussion Periods initiated during June shall be completed. Recovery Auditors shall not accept new Discussion Period requests after July 1, Recovery Auditors shall continue to maintain their customer service areas (telephone lines and appropriately training staff) and process for escalating concerns, until further notice. Recovery Auditors shall continue to support the appeal process. Note: Medicare Administrative Contractor (MAC) processes will continue. Therefore, claims sent for adjustment, by a Recovery Auditor, on or before June 1, 2014 may complete the adjustment process on, or after, June 2, The Medicare Appeals process will also continue. Therefore, recoupments can occur, if a provider does not file a timely appeal (to the 1st or 2nd level of appeal), or receives an unfavorable decision at the 2nd level (QIC) of the appeals process. Recovery Audit Program Pause on Sending Additional Documentation Requests to Providers CMS recently announced a pause in the Recovery Audit program in order to transition down the current contracts in anticipation of awarding the next round of Recovery Audit program contracts within the next few months. The following are some important dates:

9 February 21 is the last day a Recovery Auditor may send a postpayment Additional Documentation Request (ADR) February 28 is the last day a MAC may send prepayment ADRs for the Recovery Auditor Prepayment Review Demonstration June 1 is the last day a Recovery Auditor may send improper payment files to the MACs for adjustment New Approved RAC Issues Performant Recovery Region A No new Part A approved issues at this time. Performant will be performing the Recovery Auditor Prepayment Review Demonstration in the following states: New York Pennsylvania Performant Recovery website: CGI Region B No new Part A approved issues at this time. CGI will be performing the Recovery Auditor Prepayment Review Demonstration in the following states: Illinois Michigan Ohio CGI website: Connolly Region C On February 10, 2014, the following issue was approved for audit: Medical Necessity: Percutaneous Transluminal Angioplasty

10 On February 4, 2014, the following issue was approved for audit: Hospice: Medicare Coverage Requirement Review Connolly will be performing the Recovery Auditor Prepayment Review Demonstration in the following states: Florida Louisiana Texas North Carolina Connolly website: HDI Region D No new Part A approved issues at this time. HDI will be performing the Recovery Auditor Prepayment Review Demonstration in the following states: California Missouri HDI website: Copyright 2014 Executive Health Resources, Inc. All rights reserved. No part of this report may be reproduced or distributed. Permission to reproduce or transmit in any form or by any means electronic or mechanical, including presenting, photocopying, recording and broadcasting, or by any information storage and retrieval system must be obtained in writing from Executive Health Resources. Requests for permission should be directed to INFO@EHRDOCS.COM.