Medicare Compliance & Reimbursement

Plus:  Medically unlikely edits are back.

The annual update notice of new payment rates for skilled nursing facilities will increase next year.

Medicare payments to nursing homes will increase by approximately $560 million in 2007, CMS
announced.

This is a 3.1 percent increase that accompanies plans to:

1. Develop an integrated system of post-acute care payment and to make payments for similar services consistent regardless of where the service is delivered;
 
2. Encourage the increased use of health information technology to improve both quality and efficiency in delivering post-acute care;

3. Assist beneficiaries in their need to be better informed health care consumers by making information about health care pricing and quality accessible and understandable; and

4. Accelerate the progress already being made in improving quality of life for nursing home residents.

"These new payment rates reflect our commitment to improving the quality of care in the long-term care setting while maintaining predictability and stability in payments for the nursing home industry," said CMS Administrator Mark B. McClellan, MD, PhD. "They will enable nursing homes and the Medicare program to continue to move forward in providing quality services for patients who need post-acute care."

The new payment rates also include a special adjustment made to cover the additional services required by nursing home residents with HIV/AIDs, the agency reports.

The SNF PPS update notice is on the CMS Web site at http://www.cms.hhs.gov/providers/snfpps.

2,800 Edits Target 'Non-Controversial' Topics

A drastically unpopular set of edits is back for yet another go-around.

The Centers for Medicare & Medicaid Services (CMS) almost scrapped the controversial medically unbelievable edits (MUEs) but instead renamed them medically unlikely edits.

Either way, they're still designed to test particular codes against a maximum number of units of service. These edits will auto-deny or auto-suspend any claims where the units exceed the maximum. The carrier staff won't review these denials unless there are limitations in the shared system.

The approximately 2,800 new edits will apply to "non-controversial" anatomic considerations, CMS says.

Good news: The MUEs won't apply to all services, CMS says in Transmittal 155. For example, CMS has no plans to develop MUEs for anesthesia services. CMS also says it will set the maximum units high enough for each service to allow "medically reasonable daily frequencies of clinical outpatient services provided in most outpatient or provider settings."

You can bring any concerns you may have about a particular MUE to the Correct Coding Initiative coordinator, AdminaStar Federal.

Note: You can't bill your patient for any excess charges denied by the MUEs, CMS clarifies. You also won't be able to appeal these denials.

CMS Releases Long-Awaited Quality Standards For DMEPOS Suppliers

After receiving thousands of comments from suppliers of durable medical equipment prosthetics, orthotics and supplies, the Centers for Medicare and Medicaid Services announced Aug. 15 that it has published the new quality standards.

CMS issued the quality standards in response to Section 302(a)(1) of the Medicare Modernization Act that "requires the Secretary to establish and implement quality standards to be applied by recognized independent accreditation organizations," the agency reported in an Aug. 15 release.

"Suppliers must comply with the quality standards in order to furnish any Durable Medical Equipment (DME), prosthetic device, prosthetic, or orthotic item or service for which Part B makes payment, and also in order to receive or retain a provider or supplier billing number used to submit claims for reimbursement for any such item or service for which payment can be made by Medicare," says CMS.

At the Aug. 15 Home Health & DME Open Door Forum, CMS spokesperson Linda Smith told participants that the final standards reflect "significant revisions to reduce the burden of the requirement on small suppliers."