Clarification Of CMS’ Final Rule Language Addressing 30 Day Therapy Reassessment Change

CMS has clarified the final rule language that appeared in the Federal Register on November 6, 2014, entitled “Medicare and Medicaid Programs; CY 2015 Home Health Prospective Payment System Rate Update; Home Health Quality Reporting Requirements; and Survey and Enforcement Requirements for Home Health Agencies.” The 30 day reassessment applies to episodes that begin on or after January 1, 2015. There was an inconsistency error in the final rule where it stated “ending on..” in one place and “beginning on…” in another. CMS has clarified that it meant to state the therapy reassessment changes finalized in the regulations are effective for episodes beginning on or after January 1, 2015. Every 30 days, a qualified therapist must provide the needed therapy service and functional reassessment of the patient. If more than one discipline of therapy is provided, a qualified therapist from each of the disciplines must provide the needed therapy service and functionally reassess the patient at least every 30 days.

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Medicare Plans To Cover Lung Cancer Screening In High-Risk Groups

CMS has proposed covering annual, low-dose computed tomography screening for lung cancer in patients at high risk. In order to be eligible for screening, patients must meet the following criteria:

  • Current smoker or smoker who has quit in the past 15 years
  • 30 pack-year history or equivalent
  • Aged 55-74

In order to be screened, patients will need to undergo counseling to discuss the risks and benefits of screening and smoking cessation.

Medicare is expected to release its final rule in February.

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CMS Final Rule: Key Revisions To Medicare’s 2015 Physician Fee Schedule

Physicians have mixed feelings about the final rule CMS issued last week that includes Medicare’s 2015 physician fee schedule. The rule also revises the agency’s policies on telehealth and paying different rates for the same service depending on where it was delivered. However, physicians were the most concerned with the potential that physician payments will be subject to a 21.2% cut driven my Medicare’s sustainable growth-rate payment formula on April 1 (unless Congress decides against it).

One of the highlights of the rule is the creation of a monthly care-management fee for patients with two or more chronic conditions. CMS has set the fee at $42.50 and has “backed away” from the previously proposed requirement that only physicians using 2014 edition-certified software would be able to collect the fee. The new final rule allows physicians using 2011 edition EHRs to collect fees. Physicians are also commending CMS for rewarding care coordination. However, they are also expressing concern over the administrative burdens associated with documenting non-face-to-face management services that could outweigh the benefits of the new payment. They believe the care-coordination fee should be higher due to the level of work involved.

Key changes in the final rule include CMS taking action on the Medicare Payment Advisory Commission’s recommendation for site-neutral reimbursement for similar services delivered in different settings. MedPAC intends to make rates the same whether the patient is seen at hospital or a physician’s practice. CMS will “study the issue and create new codes designating whether services were provided off or on a hospital campus so it can examine the trends in Medicare payment and beneficiaries’ cost-sharing as hospitals acquire physician practices and bill services they deliver as hospital-based outpatient care.”

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CMS: Providers To Receive ICD-10 Software 6 Months In Advance

In its final rule, CMS has announced that providers will receive coding and billing software six months before the ICD-10 transition date. This is double the lead time that providers had for a planned 2014 transition. The switch to ICD-10 was originally planned to take place on October 1, 2014, but was delayed until October 1, 2015. In its final rule, CMS noted that “several commenters” had asked for additional lead time. Providers had expressed “anxiety” over the transition, saying CMS was not offering the necessary support. In the coming months, CMS plans on carrying out “additional outreach” and is also encouraging providers to take full advantage of the additional lead-time to prepare their systems to submit the new codes.

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Final Rule Fails To Promote Home Health EHRs

The final rule for the Medicare home health prospective payment system for CY 2015 includes language on the use of electronic health records by home health agencies. In the final rule, CMS says that the Department of Health and Human Services (HHS) will continue to promote the adoption and implementation of certified EHRs but doesn’t explicitly state that HHS encourages their use in a home health setting.

Last month, the proposed rule on Medicare and Medicaid Conditions of Participation for Home Health Agencies encouraged “home health providers to use-and their health IT vendors to develop-ONC-certified HIT/EHR technology to support interoperable health information exchange with physicians, hospitals, other long-term and post-acute care providers, and their patients.” The final rule also states that the ONC expressed in the 2014 Edition Release 2 final rule an intention to propose future changes to the ONC HIT Certification Program that would permit the certification of health IT for other health care settings, including long term and post acute care and behavioral health settings.

In a meeting of the HIT Policy Committee’s certification and adoption workgroup, the Pennsylvania Homecare Association (PHA) submitted a written comment which argued for the establishment of voluntary EHR certification criteria. PHA representatives stated that even if these criteria were put in place, EHR adoption among home health providers could start to “level off or even decrease” since they are not eligible for the monetary and technical assistance provided under the HITECH Act.

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Final Rule Allows Data Mining Matching Funds

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a final rule allowing State Medicaid Fraud Control Units (MFCU) to receive federal matching funds to identify fraud through data mining, statistical models which identify abnormal utilization and billing practices. The regulations go into effect on June 17, 2013.

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Physician Information Publicly Disclosed Per Sunshine Act

Physicians have until August 1, 2013 to start reporting to the government on applicable gifts and payments from drug and device manufacturers reporting now that the Centers for Medicare & Medicaid Services (CMS) has issued the final rule on the Physician Payment Sunshine Act.

Information that will be publicly disclosed about physicians as a result of the final rule include:
  • Physician’s name and business address
  • Physician’s NPI, state license number and specialty
  • Amount and date of the benefit received by the physician
  • Form of the benefit
  • Nature of the benefit
  • Name of the covered product, if the payment is for marketing, education, or research related to a specific drug, device, or biological
  • An indication as to whether the benefit is subject to delayed publication
  • If the benefit is made to an entity or individual at the request of a covered recipient, the name of the other entity or individual
  • An indication as to whether the benefit was provided to a physician holding an ownership or investment interest in the manufacturer
  • If desired, a statement that provides additional context for the benefit

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