CMS URGENT UPDATE
Centers for Medicare & Medicaid Services (CMS)
published the 2016 Medicare Physician Fee Schedule (MPFS)
final rule in the Federal Register on October 30, 2015.
CMS notified providers that in order to implement
corrections to technical errors discovered after
publication of the MPFS rule and process claims
correctly, Medicare Administrative Contractors (MACs)
will hold claims containing 2016 services paid under the
MPFS for up to 14 calendar days, (i.e., Friday, January
1, 2016 through Thursday, January 14, 2016).
believes this hold should have minimal impact on
provider cash flow as, under current law, clean
electronic claims are not paid sooner than 14 calendar
days (29 days for paper claims) after the date of
receipt. What CMS failed to mention in this notice is
whether the payment floor is applicable when the claims
are processed, e.g., a 01/04/2016 claim is processed on
01/10/2016. Historically, CMS has not waived the 14-day
and 29-day payment floors when claims have been held for
claims for services rendered on or before Thursday,
December 31, 2015 are unaffected by the 2016 claims hold
and will be processed and paid under normal procedures
and time frames.
Health Professionals: Information Regarding the Medicare
Access and CHIP Reauthorization Act of 2015
President Obama Signs 'Doc Fix' Law - CF remains $35.7547 for now
with a .05% increase in July
This bill includes a provision to replace the Sustainable Growth Rate
(SGR) formula used by Medicare to pay physicians with new systems for establishing annual payment rate updates for physicians’ services.
Congress and President Obama have finally put an end to the annual 'Doc Fix' that temporarily suspended the SRG decreases in Medicare Part B fees. The new law officially called Medicare Access and CHIP Reauthorization Act of 2015
and will do the following:
Replaces the Sustainable Growth Rate (SGR) formula that cuts Medicare doctors pay.
Medicare doctors would have seen a 21% cut in April of 2015 if the fix wasn’t passed.
There have been 17 short-term patches or '
Doc-Fixes" since 2002 to avoid this
Extends the Children’s Health Insurance Program (CHIP) for two years
Cuts Medicare spending by decreasing funding to supplemental Medicare plans specifically reducing spending on “first dollar” coverage of supplemental Medigap plans enjoyed by some from 2020 onward.
Requires higher premiums for seniors who make more than $133,500 to pay more for Medicare coverage starting in 2018.
MACRA will freeze Medicare rates at pre-April levels through June, and then raise them 0.5% in the second half of the year. They will continue to increase 0.5% each year from 2016 through 2019. At the same time, MACRA will shift Medicare compensation from fee-for-service to pay-for-performance.
603 - Extension Related to Payments for Medicare
Outpatient Therapy Services
603 extends the exceptions process for outpatient
therapy caps through December 31, 2013. Providers
of outpatient therapy services are required to submit
the KX modifier on their therapy claims, when an
exception to the cap is requested for medically
necessary services furnished through December 31, 2013.
In addition, the new law extends the application of the
cap and threshold to therapy services furnished in a
hospital outpatient department (OPD), and counts
outpatient therapy services furnished in a Critical
Access Hospital towards the cap and threshold.
Additional information about the exception process for
therapy services may be found in the Medicare Claims
Processing Manual, Pub.100-04, Chapter 5, Section 10.3:
therapy caps are determined for a beneficiary on a
calendar year basis, so all beneficiaries began a new
cap for outpatient therapy services received on January
1, 2013. For physical therapy and speech language
pathology services combined, the 2013 limit for a
beneficiary on incurred expenses is $1,900. There
is a separate cap for occupational therapy services
which is $1,900 for 2013. Deductible and
coinsurance amounts applied to therapy services count
toward the amount accrued before a cap is reached, and
also apply for services above the cap where the KX
modifier is used.
603 also extends the mandate that Medicare perform
manual medical review of therapy services furnished
January 1, 2013 through December 31, 2013, for which an
exception was requested when the beneficiary has reached
a dollar aggregate threshold amount of $3,700 for
therapy services, including OPD therapy services, for a
year. There are two separate $3,700 aggregate
annual thresholds: (1) physical therapy and
speech-language pathology services, and (2) occupational
604 - Extension of Ambulance Add-On Payments
604 extends the following three Job
Creation Act ambulance payment provisions:
(1) the 3 percent increase in the ambulance fee schedule
amounts for covered ground ambulance transports that
originate in rural areas and the 2 percent increase for
covered ground ambulance transports that originate in
urban areas is extended through December 31, 2013; (2)
the provision relating to air ambulance services that
continues to treat as rural any area that was designated
as rural on December 31, 2006, for purposes of payment
under the ambulance fee schedule, is extended through
June 30, 2013; and (3) the provision relating to payment
for ground ambulance services that increases the base
rate for transports originating in an area that is
within the lowest 25th percentile of all rural areas
arrayed by population density (known as the “super
rural” bonus) is extended through December 31, 2013.
is currently revising the 2013 Medicare Ambulance Fee
Schedule (MAFS) to reflect the new law’s
requirements. In order to allow sufficient time to
develop, test, and implement the revised MAFS, Medicare
claims administration contractors may hold MAFS claims
with January 2013 dates of service for up to 10 business
days (i.e., through January 15, 2013). We expect
these claims to be released into processing no later
than January 16, 2013. The claim hold should have
minimal impact on supplier cash flow because, under
current law, clean electronic claims are not paid sooner
than 14 calendar days (29 for paper claims) after the
date of receipt. Claims with dates of service
prior to January 1, 2013, are unaffected.
of ambulance services affected by these provisions may
continue billing as usual.
605 - Extension of Medicare Inpatient Hospital Payment
Adjustment for Low-Volume Hospitals
Care Act allowed qualifying low-volume
hospitals to receive add-on payments based on the number
of Medicare discharges. To qualify, the hospital
must have less than 1,600 Medicare discharges and be 15
miles or greater from the nearest like hospital.
This provision extends the payment adjustment through
September 30, 2013, retroactive to October 1, 2012.
Be on the alert for further information about
implementation of this provision.
606 - Extension of the Medicare-Dependent Hospital (MDH)
MDH program provides enhanced payment to support small
rural hospitals for which Medicare patients make up a
significant percentage of inpatient days or discharges.
This provision extends the MDH program until
October 1, 2013, and is retroactive to October 1, 2012.
Be on the alert for further information about
implementation of this provision.
CMS released a revised version of RBRVS to fix
'Technical Problems'. This translates to a new CF
(Conversion Factor), revised RVUs, new codes and other
new revised 2015 Conversion Factor
is $35.7547 not $35.8013 as previously released
by CMS and RBRVS EZ-Fees V1.0 (See Help About).
Unless there are more problems this new fix this update
should stay in effect through March 31 when the SRG
November 13, 2014, the CY 2015 Medicare Physician Fee
Schedule (MPFS) final rule was published in the Federal
Register. In order to implement corrections to technical
errors discovered after publication of the MPFS rule and
process claims correctly, Medicare Administrative
Contractors will hold claims containing 2015 services
paid under the MPFS for the first 14 calendar days of
The hold should have minimal impact on provider cash
flow as, under current law, clean electronic claims are
not paid sooner than 14 calendar days (29 days for paper
claims) after the date of receipt.