Billing

The Centers for Medicare & Medicaid Services has issued a final rule that updates payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2017.

The rule also finalizes new quality measures for dialysis facilities treating patients with ESRD.

Here are some of the highlights of the final rule:

  • CMS projects that the updates for CY 2017 will increase the total payments to all ESRD facilities by 0.73% compared with CY 2016. For hospital-based ESRD facilities, CMS projects an increase in total hospital lab billing service payments of 0.9%, while for freestanding facilities, the projected increase in total payments is 0.7%.
  • CMS increased the base Medicare reimbursement rate to $231.55 — a $1.16 increase from 2016 rates.
  • For pediatric beneficiaries, the fixed-dollar loss amount will rise from $62.19 to $68.49, while the Medicare Allowable Payments amount will decrease from $39.20 to $38.29. For adult beneficiaries, the fixed-dollar loss amount will decrease from $86.97 to $82.92 and the Medicare Allowable Payments amount will decline from $50.81 to $45.00.
  • CMS will increase the home and self-dialysis training add-on payment adjustment. The increase was based on the average treatment times and weights for each modality, and then CMS used those times and weights as proxies for the total time spent by nurses training beneficiaries for home or self-dialysis. Using an updated RN hourly wage of $35.94 and an increase to the hours of nurse training time from 1.5 hours to 2.66 hours, the CY 2017 home and self-dialysis training add-on payment adjustment is $95.60, an increase of $45.44 from the current training add-on amount of $50.16.
  • ESRD Medicare spending is projected to increase by $80 million from CY 2016 to CY 2017.
  • CMS finalized implementation of the Trade Preferences Extension Act of 2015. This will provide coverage and Medicare reimbursement for renal dialysis services furnished on or after Jan. 1, 2017, by an ESRD facility to acute kidney injury patients. The Medicare reimbursement will be the ESRD Prospective Payment System base rate adjusted by the wage index.
  • Drugs, biologicals, laboratory services and supplies that ESRD facilities are certified to furnish, but that are not renal dialysis services, may be paid for separately when furnished to individuals with acute kidney injury.
  • CMS finalized the creation of a new Safety Measure Domain as a third category of measures for payment year (PY) 2019. CMS finalized the inclusion of the National Healthcare Safety Network (NHSN) Dialysis Event reporting measure into the ESRD Quality Incentive Program measure set for PY 2019, and then combined this measure with the existing NHSN Bloodstream Infection (BSI) clinical measure in a new NHSN BSI Measure Topic, which will be the only measure topic in this new Safety Measure Domain.
  • CMS finalized two substantive changes to the Hypercalcemia clinical measure for PY 2019 to ensure that the measure remains in alignment with the measure specifications endorsed by the National Quality Forum. These changes involve updating the measure's technical specifications for PY 2019 and future years to include plasma as an acceptable substrate in addition to serum calcium. First, CMS added plasma as an acceptable substrate in addition to serum calcium. Second, CMS changed the calculation of the revised measure to include patient-months with missing values in order to minimize any incentive for a facility to avoid reporting serum calcium data.
  • The Quality Incentive Program will include two new measures in 2020 — a standardized hospitalization ratio clinical measure and an ultrafiltration rate reporting measure.

Struggling with the laboratory medical billing process? Contact PGM to find out how our team works closely with labs like yours to develop a customized billing strategy that is designed to meet the strategic business objectives of your practice.

The Office of Inspector General (OIG) recently released a 2016 final report on Medicare payments for chiropractic services.

In its review, OIG included chiropractic services for CY 2013 for which Medicare Part B paid approximately $438 million. On the basis of its sample results, OIG estimated that approximately $359 million, or approximately 82 percent, of the $438 million chiropractic billing payments by Medicare for chiropractic services during the 2013 reporting period was unallowable; most payments did not comply with Medicare requirements.

The OIG has attributed the improper part B payments to services that were medically unnecessary, incorrectly coded, insufficiently documented or not documented to support the billed services.

The OIG stated that overpayments occurred because the Centers for Medicare & Medicaid Services' (CMS) controls requiring chiropractors to include the -AT modifier and initial treatment date on claims were not effective in preventing payments for medically unnecessary chiropractic services. OIG claim data analysis and audit results suggest that chiropractors submitted claims with the -AT modifier regardless of whether the services were for active/corrective treatment for subluxation.

Further, chiropractors submitted claims with the initial treatment date, affirming that all required documentation was being maintained on file, even though they did not document the medical necessity of the services as required by Medicare.

Finally, CMS's education of chiropractors on Medicare requirements for chiropractic services may not have been effective in preventing payments for medically unnecessary chiropractic services.

The OIG made the following recommendations to the Centers for Medicare & Medicaid Services:

  • Determine a reasonable number of chiropractic services that are necessary to actively treat spinal subluxation and implement a system edit to identify services for review in excess of that number.
  • Determine whether there should be a limit for the number of chiropractic services that Medicare will reimburse; if so, take appropriate action to put that limit into effect, and implement a system edit to disallow services in excess of that limit.
  • Improve education of chiropractors on Medicare coverage requirements for chiropractic services and the proper use of the AT modifier to ensure that only medically necessary chiropractic services are billed to Medicare.
  • Specifically identify significant obstacles to developing a more reliable control for identifying maintenance therapy and work to establish such a control. (For example, CMS could determine a reasonable length for a chiropractic treatment episode and implement a system edit to identify services for review when the number of days between the date of initial treatment and the date of service exceeds that length.)

CMS concurred with the first and third recommendation, but did not concur with the second recommendation. Regarding the fourth recommendation, CMS stated that it had responded to the same recommendation in a prior OIG report.

After reviewing CMS's comments, OIG refined two of our recommendations. The second recommendation was refined to indicate that CMS should determine whether there should be a limit for the number of chiropractic services that Medicare will reimburse and, if so, should take appropriate action to put that limit into effect. OIG also advised CMS to consider taking other appropriate actions to put such a limit into effect.

OIG also refined its fourth recommendation to specifically address CMS's comments on the recommendation in its prior report.

Resources

Here are some helpful resources for Medicare chiropractor billing compliance:

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