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centers for medicare and medicaid services

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On Thursday, June 29, 2017, the Centers for Medicare and Medicaid Services (CMS) and the Office of Medicare Hearings and Appeals (OMHA) will host a call from 1:00 pm to 3:00 pm that will focus on the recent regulatory changes to the Medicare claims appeals process. There will also be discussion surrounding the Medicare Appeals Final Rule that was published in the January 17, 2017 Federal Register, as well as the changes that are intended to streamline the administrative appeals processes, reduce the backlog of pending appeals, and increase the consistency in decision making across appeal levels.

To participate in the call, registration is required by 12:00 pm on June 29, or until the event is full. Following the presentation, time will be allocated to a session for questions and answers.

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The Centers for Medicare and Medicaid Services (CMS) announced in the May 19, 2017 Federal Register, that they will again delay the final rule that implements three new Medicare Parts A and B episode payment models (EPMs), the cardiac rehabilitation incentive payment model, as well as changes to the existing comprehensive care for joint replacement (CCJR) model. The delay in the CCJR regulation amendments will allow CMS to maintain and align policy changes with the EPMs. The final rule will now become effective on January 1, 2018.

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In the May 13, 2017 PA Bulletin, the Department of Human Services (Department) made available for public review and comment the Medical Assistance Quality Strategy for Pennsylvania.

The Department is complying with Centers for Medicare and Medicaid Services’ (CMS) requirement that states draft and implement a written quality strategy for assessing and improving the quality of health care and services furnished by managed care organizations that have a contract with the Department. As a result, the Department has developed the Medical Assistance Quality Strategy for Pennsylvania, which discusses the various quality improvement initiatives the Department has implemented to increase the quality of care for individuals receiving services through its managed care programs. The Medical Assistance Quality Strategy for Pennsylvania is not intended to comprehensively describe all the activities that the Department undertakes to assure the quality of care rendered to individuals who are receiving services through managed care programs.

The Department’s quality strategy will be used to assure that the contractors that are implementing the Department’s managed care programs are in compliance with the terms of their agreements with the Department and have committed resources to meet the following: to perform monitoring and ongoing quality improvement; to contribute to the improvement of health for the populations they serve; and to incorporate new programmatic changes to assure that the individuals they serve have timely access to high-quality care.

The Medical Assistance Quality Strategy for Pennsylvania will include programs and initiatives within the following:

  • The Office of Medical Assistance Programs, Bureau of Managed Care Operations;
  • The Office of Mental Health and Substance Abuse Services;
  • The Office of Long-Term Living Community HealthChoices;
  • CHIP; and
  • Adult Community Autism Program (ACAP).

The Medical Assistance Quality Strategy for Pennsylvania can be viewed here and interested persons are invited to submit comments regarding the Medical Assistance Quality Strategy for Pennsylvania to the Department via email. Comments received within 30 days must be reviewed and considered before the Quality Strategy is submitted to CMS for review.

Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at 800-654-5984 (TDD users) or 800-654-5988 (voice users).

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On April 27, 2017, the Centers for Medicare and Medicaid Services (CMS) released the display version of the fiscal year (FY) 2018 inpatient rehabilitation facility prospective payment system (IRF PPS) proposed rule.

Some of the key provisions are provided below; a more detailed analysis of the proposed rule with be forthcoming following the publication of the proposed rule in the May 3, 2017 Federal Register. In addition, CMS published a Fact Sheet that highlights the major provisions of the proposed rule.

ICD-10-CM Presumptive Compliance Coding Changes
CMS is proposing to make refinements to the ICD-10-CM lists used in determining IRFs’ presumptive compliance with the 60 percent rule. The complete lists of proposed code revisions are available for download on the IRF PPS website. CMS notes that the version of these lists that is finalized in conjunction with the FY 2018 IRF PPS final rule will constitute the baseline for any future updates to the presumptive methodology lists. The codes include:

  • TBI and Hip Fracture Codes

The proposed rule addresses certain ICD-10-CM diagnosis codes for patients with traumatic brain injury (TBI) and hip fracture conditions. CMS proposes to include such codes in counting towards presumptive compliance when they are used as an etiologic diagnoses in the following IGCs effective October 1, 2017:

Brain Dysfunction – 2.21 Traumatic, Open Injury;
Brain Dysfunction – 2.22 Traumatic, Closed Injury;
Orthopedic disorders – 8.11 Status Post Unilateral Hip Fracture; and
Orthopedic disorders – 8.11 Status Post Bilateral Hip Fracture.

The complete list of TBI and hip fracture ICD-10-CM codes is available for download on the CMS IRF PPS website.

  • Major Multiple Trauma Codes

CMS also proposes changes to address major multiple trauma codes that did not translate exactly between ICD-9-CM and ICD-10-CM. Specifically, CMS proposes to count IRF Patient Assessment Instruments (PAIs) that contain 2 or more of the ICD-10-CM codes from the three major multiple trauma lists that can be downloaded here. In order for patients with multiple fractures to qualify as meeting the 60 percent rule requirement for IRFs under the presumptive methodology, codes from the following lists could be used if combined as CMS describes in the proposal whereby (a) at least one lower extremity fracture is combined with an upper extremity fracture and/or rib/sternum fracture or b) fractures are present in both lower extremities:

List A: Major Multiple Trauma—Lower Extremity Fracture
List B: Major Multiple Trauma—Upper Extremity Fracture
List C: Major Multiple Trauma—Ribs and Sternum Fracture

  • Removed Codes and Other Proposals

CMS proposes to remove certain non-specific and arthritis diagnosis codes that were inadvertently reintroduced through the ICD-10-CM conversion process, and removing one ICD-10-CM code (G72.89 – Other specified myopathies) that was identified as being inappropriately applied to patients with generalized weakness, instead of to patients with clinically identified myopathies. Specifically CMS is proposing to remove 15 codes related to rheumatoid polyneuropathy with rheumatoid arthritis.

Request for Information
CMS also included a Request for Information (RFI) for continuing feedback on the Medicare Program. Feedback is requested on potential regulatory, sub-regulatory, policy, practice and procedural changes to make the delivery system less bureaucratic and complex, reduce burden for clinicians and providers, and increases quality of care while decreasing cost. CMS asked to be provided with clear and concise proposals that include data and specific examples. CMS will not respond to RFI comment submissions in the final rule, but rather will actively consider all input in developing future regulatory proposals or future sub-regulatory guidance. Ideas addressing opioid use disorder and other substance use disorders is a big area of interest.

IRF Classification Criteria
CMS is also specifically seeking stakeholder input on the 60 percent rule, including but not limited to, the list of 13 conditions used to evaluate 60 percent rule compliance.

Proposed Future Measures
Transfer of Information Measures
CMS is developing two Improving Medicare Post-Acute Care Transformation (IMPACT) Act-required measures regarding post-acute care providers’ Transfer of Information. It intends to specify these measures by October 1, 2018 and propose them for adoption in the FY 2021 IRF QRP, with data collection beginning “on or about” October 1, 2019. The measures are 1) Transfer of Information at Post-Acute Care Admission, Start or Resumption of Care from other Providers/Settings, and (2) Transfer of Information at Post-Acute Care Discharge, and End of Care to other Providers/Settings. Experience of Care and Patient-Reported Pain
CMS is developing an experience of care survey for IRFs, and survey-based measures will be developed from this survey. The survey explores experience of care across five main areas: (1) beginning stay at the rehabilitation hospital/unit; (2) interactions with staff; (3) experience during the rehabilitation hospital/unit stay; (4) preparing for leaving the rehabilitation hospital/unit; and (5) overall rehabilitation hospital/unit rating. CMS is also considering a patient-reported pain measure, Application of Percent of Residents Who Self-Report Moderate to Severe Pain (Short Stay) (NQF #0676), for future rulemaking.

Public Reporting
CMS proposes to publicly report data on six additional measures:

  • Application of Percent of Long-Term Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631) (assessment-based);
  • Application of Percent of Residents Experiencing One or More Falls with Major Injury (NQF #0674) (assessment-based);
  • Medicare Spending Per Beneficiary-PAC IRF QRP (claims-based);
  • Discharge to Community-PAC IRF QRP (claims-based);
  • Potentially Preventable 30-Day Post-Discharge Readmission Measure for IRF QRP (claims-based); and
  • Potentially Preventable within Stay Readmission Measure for IRFs (claims-based).

Comments on the proposed rule will be accepted until June 27, 2017. Discussion on the provisions of this proposed rule will be included as an agenda topic at the June Medical Rehabilitation Committee meeting.

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In the March 21, 2017 Federal Register, the Centers for Medicare and Medicaid Services (CMS) published an interim final rule with comment period (IFC) to again delay the effective date of the final rule (originally published in the January 3, 2017 Federal Register), implementing the three new Medicare Parts A and B episode payment models, changes to the existing Comprehensive Care for Joint Replacement (CJR) Model, and the Cardiac Rehabilitation Incentive model. The effective date has been delayed from March 21 to May 20. According to the interim final rule, the delay is necessary to allow time for additional review. The new payment models and the updated CJR Model allow clinicians additional opportunities to qualify for a five percent incentive payment through the Advanced Alternative Payment Model (APM) path under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the Quality Payment Program.

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The Centers for Medicare and Medicaid Services (CMS) recently announced a Medicare Learning Network (MLN) call that will focus on the Standardized Patient Assessment Data Collection Project. The call has been scheduled for Wednesday, March 29, 2017, from 1:30 pm to 3:00 pm EDT

During the call, information will be shared about the efforts to develop, implement, and maintain standardized Post-Acute Care (PAC) patient assessment data, including pilot testing results and plans for an upcoming national field test. Additional agenda topics include:

  • Goal of the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act);
  • Timeline of activities;
  • Alpha 1 results;
  • Alpha 2 progress;
  • Plans for beta test; and
  • How to get involved.

The IMPACT Act requires the reporting of standardized patient assessment data by PAC providers, including inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), home health agencies (HHAs), and long-term care hospitals (LTCHs).

To register for the call, please visit the MLN Registration page.

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The Centers for Medicare and Medicaid Services (CMS) published a final rule; delay of effective date notice in the February 17, 2017 Federal Register that delays the effective date of the rule, “Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement (CJR) model.” This notice clarifies that, in accordance with the White House’s regulatory freeze, provisions of CMS’ bundled payment final rule that were to become effective on February 18, 2017, are now delayed until March 21, 2017.

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On February 23, 2017, from 1:30 pm to 3:00 pm, the Centers for Medicare and Medicaid Services (CMS) will host a call, “Looking Ahead: The IMPACT Act in 2017,” focusing on the Improving Medicare Post-Acute Care Transformation (IMPACT Act) of 2014. The IMPACT Act requires the reporting of standardized patient assessment data by post-acute care (PAC) providers, including inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), home health agencies (HHAs), and long-term care hospitals (LTCHs). Agenda topics during this call will include the requirements, goals, progress to date, and key milestones for 2017. CMS will also convene a question and answer session following the presentation. To participate in the call, registration is required.

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The Centers for Medicare and Medicaid Services (CMS) conducted a national provider call on January 12, 2017, that focused on therapy information data collection for the inpatient rehabilitation facility patient assessment instrument (IRF-PAI). The therapy information section on the IRF-PAI was finalized in the fiscal year (FY) 2015 IRF prospective payment system (PPS) final rule. The call included a review of examples of each type of therapy and how to accurately code and complete the therapy information section on the IRF-PAI. To assist with the call, CMS utilized a PowerPoint presentation for providers to refer to. The written transcript and audio recording of the national provider call will be posted in approximately two weeks.

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On December 20, 2016, the Centers for Medicare and Medicaid Services (CMS) announced the release of a final rule that will implement three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement (CJR) model under Section 1115A of the Social Security Act.

The finalization of these new Innovation Center models will continue the shift of Medicare payments from rewarding quantity to rewarding quality by creating incentives for hospitals to deliver better care to patients at a lower cost. The models will reward hospitals that work together with physicians and other providers to avoid complications, prevent hospital readmissions, and speed recovery.

The announcement finalizes significant new policies that:

  • Improve orthopedic care: One new payment model will support clinicians in providing care to patients who receive surgery after a hip fracture, other than hip replacement. In addition, CMS is finalizing updates to the CJR Model, which began in April 2016.
  • Improve cardiac care: Three new payment models will support clinicians in providing care to patients who receive treatment for heart attacks, heart surgery to bypass blocked coronary arteries, or cardiac rehabilitation following a heart attack or heart surgery.
  • Provides an accountable care organization (ACO) opportunity for small practices: The new Medicare ACO Track 1+ Model will have more limited downside risk than Tracks 2 or 3 of the Medicare Shared Savings Program in order to encourage more practices, especially small practices, to advance to performance-based risk.

The final rule makes several modest adjustments to the CJR Model that are largely conforming changes for consistency with the other episode payment models. These include refinements for use of the skilled nursing facility waiver, exclusion of beneficiaries participating in selected ACOs, and revising target pricing methodology to include reconciliation and repayment amounts for performance years 3, 4, and 5. CMS is finalizing revisions to the quality adjustment to incorporate improvement as well as absolute performance, and also finalized changes to align CJR with the episode payment models around financial arrangements and beneficiary engagement incentives, compliance enforcement, appeals processes, and beneficiary notifications.

The final rule is scheduled to be published in the Federal Register on January 3, 2017, and is effective on February 18, 2017.

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