CMS Delays RCD for 60 Days
Last month, the Centers for Medicare & Medicaid Services (CMS) announced a delayed phase-in of the Review Choice Demonstration (RCD) to help ease the transition to RCD during the current COVID-19 Public Health Emergency (PHE). This means home health agencies (HHAs) in Florida and North Carolina could start participating in the pre-claim review process beginning August 31, 2020, but they are not required to do so.
Claims submitted without pre-claim review will process as normal and will not be subject to a 25% payment reduction, according to CMS, but routine post-payment medical review processes will continue.
Providers in Florida and North Carolina who have already made an RCD choice selection do not need to take further action if they choose not to participate. CMS said it will reassess this phased-in approach in 60 days.
For HHAs in Illinois, Ohio and Texas, this means:
- Cycle 2 in Illinois and Cycle 1 in Texas will end September 30, 2020.
- Affirmation and claim approval rates will be calculated based on review decisions made between February 1, 2020, and September 30, 2020, for Illinois providers and between March 2, 2020, and September 30, 2020, for Texas providers.
- Cycle 2 in Ohio began on August 31, 2020.
- Claims submitted under Choice 1 without going through the pre-claim review process will not face a 25% payment reduction until further notice, but will be subject to prepayment review.
In late March 2020, CMS decided to pause RCD for HHAs in Illinois, Ohio and Texas, and said it would not start the demonstration in North Carolina or Florida until the PHE ended. Despite the PHE being renewed until at least October 23, 2020, CMS said it was renewing RCD for participating states beginning August 3, 2020.
However, providers – whose resources have been strained as they continue to fight COVID-19 – protested an August restart of RCD. The Home Care Association of Florida reported that providers sent more than 11,500 emails to CMS and members of Congress to protest the decision to restart RCD. In response, CMS announced the delayed phase-in.
CWF to Start Sending Hospice DOEBA, DOLBA Changes to MBD
CMS has requested that the Common Working File (CWF) start sending hospice DOEBA and DOLBA data to the Medicare Beneficiary Database (MBD). CMS also has asked that CWF begin sending a one-time extract for all beneficiaries’ hospice DOEBA and DOLBA dates and days used for the past four years from the October 5, 2020, implementation date.
Beneficiary detail information is passed from the CWF to the MBD via an extract file. CWF currently sends Hospice Election dates, Revocation code, Hospice Periods and National Provider Identifier (NPI) information to MBD via an extract file, but Hospice Date of Earliest Billing Activity (DOEBA) and Date of Latest Billing Activity (DOLBA) data are not included on the extract file. That means the Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS) can’t return Hospice DOEBA and DOLBA dates to Medicare providers.
Because Medicare guidelines require sequential billing for hospice, Medicare providers have to wait until all prior hospice billing from a provider has been completed before submitting the 81C to reflect the patient transfer. The Integrated User Interface (IUI) database does have Hospice Billing dates but HETS is missing the billing dates for any previous hospice periods, which makes it difficult for providers to confirm for hospice sequential billing.
HETS receives and processes Medicare eligibility requests and returns eligibility and benefit details to providers. The HETS system retrieves the data it returns from the IUI, which is fed with data that is initially sourced from the CWF, Enrollment Database and Medicare Advantage Prescription Drug database.
Starting October 5, CMS requests that CWF start sending the Hospice DOEBA and DOLBA dates and days used in the extract to MBD, as well as send a one-time extract for all beneficiaries’ hospice DOEBA and DOLBA dates.
AMA Code Set Updates Proposed for CMS Adoption Jan. 1, 2021
The American Medical Association (AMA)’s recently published 2021 Current Procedural Terminology (CPT®) includes the first major overhaul of codes and guidelines in more than 25 years for office and other outpatient evaluation and management (E/M) services.
According to the AMA, the changes were designed to make E/M office visit coding and documentation easier and more flexible, reducing administrative burdens for physicians and staff. The changes to CPT codes ranging from 99201-99215 are proposed for adoption by the Centers for Medicare and Medicaid Services on Jan. 1, 2021.
The E/M office visit modifications include:
- Eliminating history and physical exam as elements for code selection.
- Allowing physicians to choose the best patient care by permitting code level selection based on medical decision-making (MDM) or total time.
- Promoting payer consistency with more detail added to CPT code descriptors and guidelines.
“To get the full benefit of the burden relief from the E/M office visit changes, healthcare organizations need to understand and be ready to use the revised CPT codes and guidelines by Jan. 1, 2021,” said AMA President Susan R. Bailey, M.D. “The AMA is helping physicians and healthcare organizations prepare now for the transition and offers authoritative resources to anticipate the operational, infrastructural and administrative workflow adjustments that will result from the pending transition.”
To help providers adjust to the revised E/M office visit codes and guidelines, the AMA has developed an extensive online resource library that includes a checklist, videos, modules, guidebooks, as well as other tools and resources.
The revised E/M office visit codes are among 329 editorial changes in the 2021 CPT code set, including 206 new codes, 54 deletions, 69 revisions. Among this year’s important additions to the CPT code set are new medical testing services sparked by the public health response to the COVID-19 pandemic. New codes for retinal imaging (92229) and external extended electrocardiogram (ECG) monitoring are also included. The CPT code set has been modified with several code additions and revisions that have been approved for immediate use and published for the 2021 CPT code set.
RAP Phase-Out Begins January 1
RAPs are set to be phased out beginning Jan. 1, 2021. However, all home health agencies (HHAs) must continue to submit a no-pay RAP until Jan. 1, 2022. Providers should note new rules and deadlines pertaining to the RAP phase-out.
The Centers for Medicare and Medicaid Services (CMS) has finalized a non-timely submission payment reduction for when an HHA does not submit the RAP within five calendar days from the start of care date for the first 30-day period of care in a 60-day certification period and within five calendar days of day 31 for the second 30-day period of care in the 60-day certification period.
HHAs will have a new notice of admission (NOA) requirement, which will replace the RAP entirely starting in 2022 and comes with built-in penalties. For more on how the RAP phase-out will affect your HHA, read our white paper and register for our webinar, “Home Health Proposed Rule: RAPs, NOAs, and How to Prepare for 2021,” featuring Melinda Gabourey, COS-C, CEO and founder of Healthcare Provider Solutions Inc.
Open Payments: CMS to Add 5 Provider Types in 2021
Every year, drug and medical device companies report payments or other transfers of value made to physicians and teaching hospitals (covered recipients). Providers get an opportunity to review your data before CMS publishes it on the Open Payments website in June each year. In 2021, CMS will add five new provider types as covered recipients:
- Physician assistants
- Nurse practitioners
- Clinical nurse specialists
- Certified registered nurse anesthetists and anesthesiologist assistants
- Certified nurse midwives