10/16/2018

CMS-Medicare

Recent Oncology Related Articles

Medicare Advantage Plans Found to Improperly Deny Many Claims

WASHINGTON — Medicare Advantage plans, the popular private-insurance alternative to the traditional Medicare program, have been improperly denying many medical claims to patients and physicians alike, federal investigators say in a new report.  READ MORE

CMS announces 2019 Medicare Parts A & B premiums and deductibles

On October 12, 2018, the Centers for Medicare & Medicaid Services (CMS) released the 2019 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs.  The standard monthly premium for Medicare Part B enrollees will be $135.50 for 2019, a slight increase from $134 in 2018. READ MORE

Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims — Reminder

A 2017 Office of the Inspector General (OIG) report noted that, in some cases, pharmacies incorrectly billed Medicare Part B for claims using the KX modifier for immunosuppressive drugs. It is estimated that Medicare paid $4.6 million for these claims that did not comply with Medicare requirements.
In response to this report, CMS clarified manual instructions on the use of the KX modifier to help pharmacies document the medical necessity of organ transplant and eligibility for Medicare coverage. Resources for pharmacies:

• CMS and Its Claims Processing Contractors Issued Conflicting Guidance on the Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims OIG Report, August 2017
• Pharmacy Billing of Immunosuppressive Drugs MLN Matters Article
• Clarification of the Billing of Immunosuppressive Drugs MLN Matters Article

Physician Compare: Preview Period and Public Reporting Webcast — October 30

Tuesday, October 30 from 1:30 to 3 pm ET

Register for Medicare Learning Network events.

Are you interested in learning more about Physician Compare? Find out about the:

• 2017 Quality Payment Program performance information targeted for public reporting
• Upcoming 30-day preview period

Learn how to review your performance information before it is publicly reported. A question and answer
session follows the presentation. 

LCDs MLN Matters Article — New

A new MLN Matters Article MM10901 on Local Coverage Determinations (LCDs) is available. Learn about detailed changes to the LCD process.

ABNs and Dual Eligible Beneficiaries: Special Guidelines

When Advance Beneficiary Notices (ABNs) are issued to dual eligible beneficiaries, including Qualified
Medicare Beneficiaries (QMBs), distinct billing limitations apply. See QMB Billing Requirements FAQs pages 6 and 7 for special instructions and guidelines.

For More Information:

• QMB Program webpage
• ABN webpage

QRURs and PQRS Feedback Reports: Access Ends December 31

The final performance period for the Value Modifier and Physician Quality Reporting System (PQRS) programs was 2016 and the final payment adjustment year is 2018. Quality and Resource Use Reports (QRURs) and PQRS Feedback Reports will no longer be available after the end of 2018. If you need these reports, download them through December 31, 2018. Visit the How to Obtain a QRUR webpage for more information.

For access to PQRS Taxpayer Identification Number or National Provider Identifier reports from program year 2013 or earlier, contact the QualityNet Help Desk. They are no longer available from the QualityNet Secure Portal.

The Merit-based Incentive Payment System (MIPS) under the Quality Payment Program replaced the Value Modifier and PQRS programs. Visit the Quality Payment Program website to learn more. Note: QRURs and PQRS Feedback Reports are not same as the MIPS Performance Feedback.

For More Information:

• PQRS Analysis and Payment webpage: Information on PQRS Feedback Report
• Value-Based Payment Modifier webpage: Information on QRURs
• For assistance with Enterprise Identity Management or PQRS Feedback Reports , contact the
  QualityNet Help Desk
• For assistance with the QRURs or Value Modifier, contact the Physician Value Help Desk at
  pvhelpdesk@cms.hhs.gov or 888-734-6433 (select option 4)

Quality Payment Program: MIPS Resources

CMS posted new Merit-based Incentive Payment System (MIPS) resources:

• 2019 Virtual Groups Toolkit: Includes an overview fact sheet, an election process fact sheet, a sample virtual group election submission email, and a virtual group agreement template
• 2018 Cost Performance Category Fact Sheet (updated): Includes information on how the cost
  performance category is weighted and scored
• 2018 Claims Data Submission Fact Sheet: Provides details on how to submit Quality performance category data
• 2018 MIPS Specialty Measures Guides for Anesthesiologists and Certified Registered Nurse
  Anesthetists, Cardiologists, and Radiologists: Highlights a list of measures and activities for the Quality, Cost, Improvement Activities and Promoting Interoperability performance categories
• MIPS Data Validation Criteria: Includes an overview fact sheet and the 2018 criteria used to audit and validate data submitted in the Quality, Improvement Activities, and Promoting Interoperability performance categories
• 2018 Eligible Measure Applicability (EMA) Resources: Provides an overview of the EMA process and lists individual quality measures for both registry and claims data submission

For More Information:

• 2018 Resources webpage
• Contact the Quality Payment Program at QPP@cms.hhs.gov or 866-288-8292 (TTY: 877-715-6222)

Improper Payment for Intensity-Modulated Radiation Therapy Planning Services

In a recent report, the Office of Inspector General (OIG) determined that payments for outpatient IntensityModulated Radiation Therapy (IMRT) did not comply with Medicare billing requirements. Specifically, hospitals billed separately for complex stimulations when they were performed as part of IMRT planning. Overpayments occurred because hospitals are unfamiliar with or misinterpreted CMS guidance.

Use the following resources to bill correctly:

• IMRT Planning Services Editing MLN Matters® Article
• Medicare Improperly Paid Hospitals Millions of Dollars for IMRT Planning Services OIG Report, August 2018
• Medicare Claims Processing Manual, Chapter 4, Section 200.3.1
• July 2016 Update of the Hospital Outpatient Prospective Payment System MLN Matters Article

Open Payments: Key Thresholds for Program Year 2019 Reporting

Open Payments key (de minimis) thresholds for reporting are adjusted based on the consumer price index. Small payments or transfers of value of less than $10.79 do not need to be reported, except when the total annual value of payments or other transfers of value to a covered recipient exceeds $107.91 for Program Year 2019 (data collected from January 1 through December 31, 2019).

For More Information:

• Open Payments website
• For questions, contact the Help Desk at openpayments@cms.hhs.gov or 855-326-8366, (TTY 844-649-2766)

Open Payments: Program Year 2019 Teaching Hospital List

The Open Payments Program Year 2019 teaching hospital list is available in PDF or Excel formats. The list identifies which teaching hospitals are eligible for reporting in Program Year 2019 (data collected from January 1 through December 31, 2019).

For More Information:

• Open Payments website
• For questions, contact the Help Desk at openpayments@cms.hhs.gov or 855-326-8366, (TTY 844-649-2766)

Physician Compare: Public Reporting Webinar Materials

A recording and transcript of the Public Reporting on Physician Compare: What you Need to Know webinar is available on the Physician Compare Initiative website. Contact PhysicianCompare@Westat.com if you have questions.

Annual Clotting Factor Furnishing Fee: 2019 Update MLN Matters Article 

A new MLN Matters Article MM10918 on Annual Clotting Factor Furnishing Fee Update 2019 is available. Learn about the furnishing fee paid for items and services associated with clotting factor.

Influenza Vaccine Payment Allowances: Annual Update MLN Matters Article 

A new MLN Matters Article MM10914 on Influenza Vaccine Payment Allowances - Annual Update for 2018-2019 Season is available. Learn about payment allowances for influenza virus vaccines updated on August 1.

Influenza Virus Vaccine Code: January 2019 Update MLN Matters Article 

A revised MLN Matters Article MM10871 on Quarterly Influenza Virus Vaccine Code Update - January 2019 is available. Learn about new influenza virus vaccine code 90689.

 Medicare Enrollment for Physicians, NPPs, and Other Part B Suppliers Booklet — Reminder

The Medicare Enrollment for Physicians, Non-Physician Practitioners (NPPs), and Other Part B Suppliers Booklet is available. Learn about:

• Who are Part B suppliers
• Enrolling in the Medicare Program
• Determining if you want to be a participating provider

Recent LearnResource & MedLearn Matters Articles

• Local Coverage Determinations (LCDs) (MM 10901)
• 2018-2019 Influenza (Flu) Resources for Health Care Professionals (SE 18015)
• Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2019 (MM 10941)
• New Waived Tests (MM 10958)
• Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2018 Update (Revised MM 10834)