IN THIS WEEK’S ISSUE:
- Beneficiaries’ Access to Part D Subsidy Explained
- JCAHO to Conduct Staffing Certification Program Reviews Biennially
- CMS Corrects Codes for 2006 Oncology Demonstration Project
- CMS Revises Electronic Reporting Requirements of OASIS Data
- Payment Policy Requirements for Nursing Facilities
- CMS Issues Instructions on Calculating FQHC Supplemental Payments
- Section 1011 Payment Request Deadline Extended Again
- Quick Links
- New in the Resource Center
1. BENEFICIARIES’ ACCESS TO PART D SUBSIDY EXPLAINED
In a December 30 final rule, the Social Security Administration (SSA) has described the process for determining when and how beneficiaries can get a subsidy to help with their Medicare drug benefit premium and cost sharing. Included in the rule are: how the initial determination of eligibility is made; how the subsequent redetermination will be done; how to apply for the subsidy; how a determination decision can be appealed; and how the SSA will evaluate income and resources.
Those wanting to receive the subsidy must file an application, have a determination of eligibility made, and enroll with an authorized Medicare Part D prescription drug provider. However, Medicare beneficiaries covered by Medicaid, who are enrolled in a Medicare Savings Program with their state, or who receive supplemental security income are automatically eligible for the subsidy and do not need to apply.
2. JCAHO TO CONDUCT STAFFING CERTIFICATION PROGRAM REVIEWS BIENNIALLY
The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) will conduct on-site reviews of the organizations participating in its Health Care Staffing Services Certification program every two years instead of each year, the agency announced December 30, 2005. JCAHO says that the shift from an annual to a biennial review cycle is consistent with its other certification programs. In order to reinforce the expectation of consistent compliance with its standards and to stress the continuous nature of the certification process, JCAHO will enhance the certification requirements. As part of the enhancements, at the mid-point of the review cycle, organizations will be required to complete a periodic performance review in which they will evaluate their compliance with JCAHO standards.
The certification results will be publicly disclosed, JCAHO says, and certified healthcare staffing firms will be listed on the commission’s web site, allowing healthcare organizations easy access to information about local and national healthcare staffing firms.
3. CMS CORRECTS CODES FOR 2006 ONCOLOGY DEMONSTRATION PROJECT
CMS has rescinded demonstration transmittal number 34, dated December 16, 2005, and replaced it with a December 30 transmittal, number 36. The transmittals address changes and guidelines on the 2006 oncology demonstration project. According to CMS, the new transmittal corrects the ICD code range (161.0-161.9) associated with head and neck cancer and instructs carriers to hold claims between dates of service January 1, 2006, and January 16, 2006. The implementation of the new and revised material is January 17.
The oncology demonstration project replaces the 2005 chemotherapy project and will continue to gather information relevant to the quality of care for cancer patients using G-codes (81 new ones have been established). Reporting will be associated with physician evaluation and management (E&M) visits for established cancer patients who have one of 13 specific types of cancer. According to CMS, physicians will be asked to identify the primary focus of the E&M service , the current disease state, and whether the patient’s management adheres to clinical guidelines.
Only the physician specialties of hematology, medical oncology, and hematology/oncology may file demonstration claims. To qualify for the demonstration payment of $23, physicians must submit one G-code from each of three categories when an E&M service of level 2, 3, 4, or 5 is billed.
4. CMS REVISES ELECTRONIC REPORTING REQUIREMENTS OF OASIS DATA
CMS has published a new interim final rule revising provisions of a January 25, 1999, interim final rule requiring home health agencies (HHAs) to electronically report data from the Outcome and Assessment Information Set (OASIS) as a condition of participation in the Medicare program. The rule requires state agencies and CMS OASIS contractors to maintain OASIS databases according to CMS’s specifications, and establishes requirements for the release of individual patient data to ensure the confidentiality of this information.
Based on the comments received, interim final rule provisions that CMS has adopted with revisions include:
- Revised timeframe for agencies to encode and transmit OASIS data items from 7 to 30 calendar days after the assessment is completed.
- Removal of the “lock” requirement to allow HHAs the option of making corrections to OASIS data at any time without edit warnings.
The final rule becomes effective June 21, 2006.
5. CLARIFICATION OF E&M PAYMENT POLICY REQUIREMENTS FOR NURSING FACILITIES
CMS has updated the Medicare Claims Processing Manual, clarifying payment policy for E&M visits by physicians and qualified nonphysician practitioners (NPPs) in nursing facilities. According to CMS, NPPs can provide federally mandated visits and covered visits before and after the initial visit performed by a physician in a nursing facility setting. In addition, qualified NPPs not employed by the facility can perform initial visits when state law allows it.
According to CMS, the new CPT codes that are effective January 1, 2006, for billing these services include: the initial nursing facility care, per day (codes 99304-99306); subsequent nursing facility care, per day, (codes 99307-99310); and other nursing facility services (code 99318). The transmittal also elaborates on federally mandated visits, medically necessary visits, “incident to” services, prolonged services codes and other time-related services, split/shared E&M services, gang visits, and the SNF/NF discharge day management services.
6. CMS ISSUES INSTRUCTIONS ON CALCULATING FQHC SUPPLEMENTAL PAYMENTS
CMS has changed the effective date to January 1, 2006, for claims processing transmittal number 794 (dated December 29, 2005) and has corrected the manual subsection 110.3, “Billing for Supplemental Payments for FQHCs Under Contract with Medicare Advantage (MA) Plans.” The transmittal provides instructions on calculating and billing for the supplemental payments for federally qualified health centers (FQHCs) under contract with MA plans. According to CMS, supplemental payment for an FQHC will be based on a per-visit calculation subject to an annual reconciliation. The payment will be calculated by determining the differences between 100 percent of the FQHC’s all-inclusive cost-based per-visit rate and the average per-visit rate received by the FQHC from the MA organization, less the amount the FQHC may charge to MA enrollees permitted under federal law, CMS said.
To qualify for the supplemental payment, there must be a face-to-face encounter between an MA enrollee and an FQHC-covered core practitioner. Payment is made directly to each qualified FQHC through the intermediary. In addition, each FQHC seeking supplemental payment should submit a claim for each qualifying visit on type of bill 73x with revenue code 0519. Until appropriate system changes are made, CMS said FQHCs should hold all claims for the new supplemental payment. CMS expects the necessary system changes to be installed by April 3, 2006, the implementation date of the transmittal.
7. SECTION 1011 PAYMENT REQUEST DEADLINE EXTENDED AGAIN
TrailBlazer, the contractor for handling the payments authorized by Section 1011 of the Medicare Modernization Act, states in its December 28 listserv notice that the timely filing deadline for 3rd quarter FY05 payment requests has been further extended to January 16, 2006, adding more time to an earlier extension that put the due date at January 11. Under the Section 1011 policy, which pays for emergency services to undocumented aliens, providers have 180 days from the end of the federal fiscal quarter in which to file their payment requests.
8. QUICK LINKS
HOSPITAL 2006 OUTPATIENT PPS CORRECTION. CMS issued technical corrections to the 2006 hospital outpatient PPS final rule with comment period, published in the November 10, 2005, Federal Register. The corrections became effective January 1, 2006.
QUARTERLY LIST OF CMS MANUAL INSTRUCTIONS. CMS has issued a listing of all Medicare and Medicaid manual instructions, substantive and interpretive, and other notices published from July 2005 to September 2005. The notice provides national coverage determinations affecting specific medical services and identifies certain devices with an investigational device exemption number approved by the FDA that may be covered by Medicare.
FY06 HOSPICE WAGE INDEX CORRECTIONS. CMS has corrected several typographical and formatting errors in addendum tables A and C of the August 4, 2005, final rule establishing the hospice wage index for FY06. The corrections are effective October 1, 2005.
E-PRESCRIBING RULE CORRECTION. CMS corrected technical errors found in the November 7, 2005, final rule adopting standards for an electronic prescription drug program under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
MEDICARE ADVANTAGE PROGRAM CORRECTIONS. On December 23, 2005, CMS issued corrections to the January 28, 2005, rule that established the Medicare Advantage Program. Most changes are effective March 22, 2005; however, a paragraph clarifying supplemental payments from CMS to federally qualified health centers became effective January 1, 2006 (see article above).
9. NEW IN THE RESOURCE CENTER
HFMA EXECUTIVE ROUNDTABLE: TRENDS IN MANAGING LABOR COSTS. Labor is still one of the greatest expenses in most healthcare organizations. Find out what a group of healthcare finance executives are doing and what metrics they use to
better manage labor costs.
Copyright 2005 Healthcare Financial Management Association, all rights reserved. HFMA Express News ISSN: 1540-0689. Volume 13, Number 1. Editor: Rob Fromberg, rfromberg@hfma.org, (800) 252-HFMA, ext. 385.
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