Medicare Updates January 2018

TIDBITS BNP Testing OIG Updates OPPS January 2018 Update

BNP – B-Type Natriuretic Peptide Only considered “reasonable and necessary” for: Establishing a diagnosis of CHF in acutely ill patients presenting with dyspnea Predicting the long term risk of cardiac events or death across the spectrum of acute coronary syndromes when measured in the first few days after an acute coronary event. Since this situation is an inpatient service, it is not addressed in this LCD. https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34271&ver=7&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=Alabama&CptHcpcsCode=83880&bc=gAAAABAAIAAAAA%3d%3d&

BNP – B-Type Natriuretic Peptide LIMITATIONS – Non-covered in the following: Monitoring the efficiency of treatment for CHF Tailoring therapy for heart failure Since BNP is a point of service test, the primary places this would be performed outpatient is the ER or Office!

BNP – B-Type Natriuretic Peptide LIMITATIONS – Do Not do a BNP monthly for NH patients Do Not do a BNP monthly for HH patients If a patient is well enough to walk into your OP registration department, they are not sick enough to need a BNP! All Medicare patients that are a walk-in for a BNP should sign an ABN!! Drop off labs should not be done without an ABN!!

OIG Update Medicare inappropriately paid Acute-Care Hospitals for outpatient services they provided to beneficiaries who were inpatients of other facilities. $51 million paid to acute care hospitals inappropriately $14 million paid in co-pays and deductibles inappropriately The system edits that should have prevented or detected the overpayments were not working.

OIG Update Hospitals included in the audit: LTCH – Long Term Care Hospitals – both freestanding and units within acute care hospitals IRF – Inpatient Rehabilitation Facilities IPF – Inpatient Psych Facilities – both freestanding and units within acute care hospitals CAH – Critical Access Hospitals

OIG Update All of the included hospitals MUST: Provide directly all services provided during an IP stay. Arrange for services to be provided on an outpatient basis by an acute-care hospital and include those outpatient services on its inpatient claims submitted to Medicare.

OIG Update OIG recommends: CMS recover the $51 million Acute Care hospitals refund the $14 million in deductibles Identify additional improper payments outside of the audit Correct edits Educate acute care facilities

OIG Updates Medicare is losing money due to insufficient data on device replacements. Hospitals should continue to use condition codes 49 or 50 when a device is replaced due to recall or failure. CMS paid $729 million to providers who did not meet MU requirements for EHR. CMS is to review self-attestations and to recover the improper payments.

January 2018 OPPS (does not apply to CAHs)

340B Program Separately payable Part B Drugs assigned status indicator K or G acquired through the 340B Program will be paid at ASP minus 22.5%. Hospitals should use modifier JG for 340B drugs. Sole Community Hospitals are exempt and will be paid ASP plus 6%. SCH should report modifier TB for 340B drugs.

Drug Billing 2018 Many changes to HCPCS codes for drug billing in 2018 Pay close attention to billing units consistent with the HCPCS description!

Drug Reimbursements Effective 1/1/2018, payment rates for pass-through drugs have changed. CMS will not be publishing them separately. You can find payment rates updated in the January 2018 Addendum A and Addendum B. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html

DEVICE Categories Effective January 1, 2018, there are NO device categories eligible for pass-through payment. HCPCS code C2623 (Catheter, transluminal angioplasty, drug coated, non-laser) was approved on August 25, 2017, by the Food and Drug Administration (FDA) for a new indication, specifically the treatment of patients with dysfunctional Arteriovenous (AV) fistulae. Accordingly, in this January 2018 update, that is being retroactively approved for 8/25-12/31/17 when billed with CPT 36902 or 36903.

DEVICE Categories APC assignments will replace the pass-through payments. Payment will be based on reasonable cost of the device reduced by the amount included in the APC for the procedure that reflects the packaged payment for device(s) used in the procedure. OCE will determine the proper payment amount for these APCs as well as the coinsurance and any applicable deductible. All related payment calculations will be returned on the same APC line and identified as a designated new device.

Radiology Remember to use the FX modifier for x-rays done using film. Results in a 20% reduction in payment Effective 1/1/2018 use FY modifier for x-rays taken using Computed Radiography Technology/cassette based imaging. Results in a 7% reduction in payment CMS is deleting CP modifier.

Changes to the IP Only List Total Knee Arthroplasty is being removed. Several laparoscopy procedures are being removed. 43282, 43772, 43773, 43774, 55866, And 92941 related to arterial bypass grafts

Lab Update Independent laboratories may bill Medicare directly for molecular pathology tests and Advanced Diagnostic Laboratory Tests (ADLTs), which are excluded from the OPPS packaging policy, if the specimen was collected from a hospital outpatient during a hospital outpatient encounter and the test was performed following the patient’s discharge from the hospital outpatient department. Hospital Outpatient Departments (HOPDs) should no longer bill Medicare for molecular pathology tests and ADLTs performed by independent laboratories following the patient’s discharge from the HOPD, and independent laboratories will no longer have to seek payment from the HOPD for these tests, if all of the conditions are met.

Platelets Q9987 and Q9988 are deleted for 2018 Use P9073 – Platelets, pathogen reduced for Q9988 Use P9100 – Pathogen test for platelets for Q9987

OPPS Pricer Logic Rural SCHs and EACHs will continue to receive a 7.1% increase for most services in 2018. All co-payment amounts for 2018 are limited to 40% of the APC rates and cannot exceed IP deductible of $1340. Most will remain at 20%. The estimated cost of a procedure must be greater than the APC rate plus $4150 in order to qualify for an outlier payment. Rates are reduced by a ratio of 0.980 if you have not met the quality reporting guidelines.

References https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE17033.pdf https://oig.hhs.gov/oas/reports/region9/91602026.pdf https://oig.hhs.gov/oas/reports/region1/11500504.asp file:///C:/Users/Sandy/Downloads/MM10417-1%20%20jan%2018%20updates.pdf