Welcome to eSolutions’ Quarterly CMS Update!
CMS changes existing rules and introduces new ones so frequently that it’s hard to keep up! Now you don’t have to – let eSolutions, your Medicare experts, do it for you. You can count on us to inform you of CMS news, changes and new rules on a quarterly basis by subscribing to our blog.
PDGM Arrives January 1
PDGM arrives in just a few short weeks – Is your home health agency prepared for all the changes coming with this new payment model?
CMS will begin implementing PDGM on January 6, 2020, and has indicated that Requests for Anticipated Payments (RAPs) and claims will be held until its system is ready. In the final rule released October 31, CMS stated that it would move forward with behavioral adjustments. However, CMS dropped the behavioral adjustment from 8.01% to 4.36%. CMS also said it will begin phasing out pre-payment for home health services over the next year and eliminate them completely by 2021. Instead of a RAP, CMS said it will finalize a requirement for a one-time submission of a Notice of Admission (NOA) beginning in 2022.
If you are looking for more details on PDGM, eSolutions offers a wealth of resources on our website. Learn more about the final rule on behavioral adjustments, preparation tips, intake tips and more.
For more information from CMS, read this CMS MNL Matters Article.
QIES Soon Will Be iQIES
CMS has given its Quality Improvement and Evaluation System (QIES) a makeover. The system is used by providers and vendors to submit OASIS assessment data.
The enhancements are meant to make the system more reliable, scalable, secure, accessible and Cloud-based. They will occur in phases by provider type, starting with Home Health Agencies (HHAs) in January 2020. The changes include an updated name: the Internet Quality Improvement and Evaluation System (iQIES). Beginning January 1, HHAs must submit their OASIS files to iQIES or risk claim rejections and payment disruptions.
CMS uses QIES data to improve the quality and cost-effectiveness of services paid under the Medicare and Medicaid programs. The iQIES system enhancements will not change how providers currently submit data to CMS.
iQIES system enhancements include:
- System access no longer requires a virtual private network (VPN) or CMSNet. iQIESis Internet-facing and maintains the latest system architecture and security standards.
- System enhancements support flexible, user-friendly data reports for providers, which makes it easier to use real-time data for care planning and quality monitoring and improvement purposes.
- Users can access important information for work anywhere, at any time, on any device, thanks to built-in adaptability with increased accessibility.
iQIES, PDGM and OASIS-D1 all begin January 1. Under PDGM, iQIES will be critical for OASIS submissions going forward. Under PDGM, the grouper will only capture the functional score from the last OASIS assessment that was transmitted to iQIES. No other data will be captured from the OASIS assessment itself. The scores for the functional items will then be combined with claims data (diagnoses, early/late, and source of admission) to determine a HIPPS code.
Before December 23, 2019, providers must take a few critical steps in order to ensure access to iQIES. If eSolutions submits your OASIS files to CMS on your behalf, you still need to take these steps. If you don’t obtain access to iQIES by December 23, it will negatively affect your HHA’s ability to submit assessment data needed for claims matching purposes after January 1, 2020.
To learn more about the important steps to take before December 23, check out our iQIES blog post.
Read more from from CMS.
Coming in 2020: Electronic ADRs
If you use eSolutions’ Audit & Denial Management (ADM) or Medicare esMD already, we’ve got you covered. We’re adding the electronic ADR (eMDR) service to these products. When CMS is ready, we will be, too.
To sign up to receive eMDRs using our services, make sure to designate eSolutions as your CMS HIH in the NPPES system. Once you take this step, you will be set to receive your pre- and post-pay ADRs electronically. After signing up, Part A and B Medicare providers can begin receiving ADR letters electronically when the program starts. No more waiting on “snail mail” to deliver a letter. ADRs can even be printed from eSolutions’ tools, saving you more time.
With the eMDR service, you’ll see a quick turnaround on your ADRs. Once a claim hits B6001 status in FISS, you’ll get a letter in ADM and esMD 24 hours later instead of having to wait for a paper version, which could take 7-10 days.
If you’ve already designated eSolutions as your HIH, you’re ready to begin receiving ADRs as soon as the program launches. If you don’t currently use our Audit & Denial Management (ADM) or Medicare esMD already, now is the time to add these great services to your eSolutions toolbox! If you have any questions, please contact us at 866-633-4726.
Are You Set up for HETS Yet?
CMS announced it will migrate Part A provider eligibility inquiries from the Common Working File (CWF) to the HIPAA Eligibility Transaction System (HETS) beginning February 1, 2020. Since CMS intends to terminate access to the HIQA, ELGA, ELGH and HIQH eligibility systems, providers will be required to exclusively use HETS for eligibility transactions after this change.
HETS allows users to check Medicare benefits in real time over a secure connection using a HIPAA-compliant 270 eligibility request file.
If you haven’t yet transitioned your Medicare eligibility checks from the CWF to HETS, now is the time. If you’re an eSolutions customer, eSolutions’ Medicare Eligibility currently supports using HETS (Medicare EDI) for eligibility queries. If not, call us to learn how our powerful eligibility tools can help you!
Whether you’re an eSolutions customer or a provider serving Medicare Part A patients who needs more information, our simple FAQs will help you sort out this CMS initiative.
Shorter, More Frequent HCPCS Code Application Cycles Coming in 2020
CMS is updating its Healthcare Common Procedural Coding System (HCPCS) Level II coding procedures to enable shorter and more frequent HCPCS code application cycles. Starting in January 2020, CMS will implement quarterly HCPCS code application opportunities for drugs and biological product; and bi-annual application opportunities for durable medical equipment, orthotics, prosthetics and supplies, as well as other non-drug, non-biological products. This is part of CMS’ broader, comprehensive initiative to foster innovation and expedite adoption of and patient access to new medical technologies, an initiative announced in May by CMS Administrator Seema Verma.
CMS said this goal was important and required procedural changes that balance the need to code more frequently with the amount of time needed to accurately process applications. CMS has released two documents containing detailed information about the updated HCPCS Level II Coding procedures, application instructions, and deadlines for 2020, titled: “Healthcare Common Procedure Coding System (HCPCS) Level II Coding Procedures”, and “Healthcare Common Procedure Coding System (HCPCS) Level II Code Modification Application Instructions for the 2020 Coding Cycle”.
For more information, check out this CMS MLN Matters article.
CMS Sets New Modifiers to Identify PT/OT
CMS will require two new modifiers be appended to CPT codes on the claim form when those services are provided “in whole” or “in part” by a physical therapist assistant (PTA) or an occupational therapy assistant (OTA). This will be effective with dates of service beginning on or after January 1, 2020.
Modifiers are used to identify therapy services whether or not financial limitations are in effect. When there are limitations, the CWF tracks them based on the presence of therapy modifiers.
CMS has established two modifiers, CQ and CO, for services furnished in whole or in part by PTAs and OTAs, respectively, through CY 2019 PFS rulemaking:
- CQ: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant
- CO: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant
In the CY 2019 PFS final rule and in CY 2020 PFS rulemaking, CMS stated that the CQ and CO modifiers are required to be used, when applicable, for services furnished in whole or in part by PTAs and OTAs on and after January 1, 2020, on the claim line of the service alongside the respective GP or GO therapy modifier, to identify those PTA and OTA services furnished under a PT or OT plan of care.
CMS clarified that the CQ/CO modifiers apply only to services of physical and occupational therapists in private practice, not to therapy services provided by physicians or nonphysician practitioners (NPPs) ‒ including nurse practitioners, physician assistants, and clinical nurse specialists ‒ because PTAs and OTAs do not meet the qualifications and standards of physical or occupational therapists.
The CQ and CO modifiers apply to the following providers: outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and CORFs.
Providers also should note, beginning with dates of service on and after January 1, 2022, CMS said services that contain one of the two modifiers appended to them on the claim form will be paid at 85% of the normal rate of the Medicare-allowed amount for that service.