Direct Contracting creates a variety of pathways for health care providers and suppliers to take on financial risk supported by enhanced flexibilities. Because the model reduces burden, supports a focus on complex, chronically and seriously ill patients, and aims to encourage organizations to participate that have not typically participated in Medicare fee-for-service, Innovation Center models, or both, CMS anticipates that this model will appeal to a broad range of physician and other types of health organizations.

We will test two voluntary risk-sharing options:

Professional: Lower-risk option (50% shared savings/shared losses) and primary care capitation equal to 7% of the total cost of care benchmark for enhanced primary care services
Global: Full risk option (100% shared savings/shared losses) and either primary care capitation or total care capitation

The Letter of Intent (LOI) is open until December 10 for those organizations that did not submit an LOI previously. Visit the Direct Contracting Model Options webpage for more information.

See the full text of this excerpted CMS Fact Sheet (issued November 25).

DMEPOS Competitive Bidding Surveys: Comment by December 20

CMS is soliciting comments on:

Questions to ask in surveys of key stakeholders (e.g., beneficiaries, contract suppliers, and referral agents) to help us further strengthen the monitoring, outreach, and enforcement of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program
Effective methods for contacting referral agents, as they play a critical role in helping beneficiaries obtain competitively bid DMEPOS items

We will accept comments through December 20. For more information, see the Public Comments on Competitive Bidding Surveys webpage.

Quality Payment Program: Technical Expert Panel Nominations due December 20

CMS is seeking nominations to a Technical Expert Panel (TEP) that will provide guidance for activities under the Physician Cost Measures and Patient Relationship Codes contract. Nominations are due December 20. Visit the TEP webpage for more information.

Quality Payment Program: MIPS Exception Applications due December 31

If you are interested in applying for a Promoting Interoperability Hardship Exception or Extreme and Uncontrollable Circumstances Exception for the 2019 Performance Year of the Merit-based Incentive Payment System (MIPS), you must submit your application by December 31.

For More Information:

Exceptions FAQs
Automatic Extreme and Uncontrollable Circumstances Policy Fact Sheet: Learn who automatically receives the exception
Contact or 866-288-8292 (TTY: 877-715-6222)

Clinical Laboratory Fee Schedule: CY 2020 Final Payment Determinations

The Clinical Laboratory Fee Schedule (CLFS) CY 2020 Final Test Codes Payment Determinations (ZIP) are available. For more information on the payment determination process, visit the CLFS Annual Public Meeting website.

Quality Payment Program: 2019 APM Incentive Payment Details

The Quality Payment Program website is updated to include 2019 Alternative Payment Model (APM) incentive payment details. See the fact sheet for more information.

PEPPERs for Short-term Acute Care Hospitals

Third quarter FY 2019 Program for Evaluating Payment Patterns Electronic Reports (PEPPERs) are available for short-term acute care hospitals. These reports summarize provider-specific statistics for Medicare services that may be at risk for improper payments. You can use the data to support internal auditing and monitoring activities. The PEPPER files were recently distributed through a QualityNet secure file exchange to hospital QualityNet Administrators and user accounts with the PEPPER recipient role.

For More Information:

Visit the PEPPER Resources website for the user's guide, recorded training sessions, QualityNet account information, FAQs, and examples of how other hospitals are using the report
Visit the Help Desk if you have questions or need help obtaining your report
Send us your feedback or suggestions

eCQM Reporting: Updated 2020 QRDA III Implementation Guide

CMS released an update to the 2020 Quality Reporting Document Architecture (QRDA) Category III Implementation Guide for eligible clinicians and eligible professionals along with the Schematron and Comprehensive Primary Care (CPC+) Sample File to support electronic Clinical Quality Measure (eCQM) reporting. This update includes changes from the Physician Fee Schedule Final Rule.

The Implementation Guide outlines requirements for eligible clinicians and eligible professionals to report eCQMs, Improvement Activities, and Promoting Interoperability measures for the CY 2020 performance period for these programs:

Quality Payment Program: Merit-based Incentive Payment System and Advanced Alternative Payment Models
CPC+
Medicaid Promoting Interoperability Program

For More Information:

QRDA webpage
Quality Payment Program website
For questions about the Implementation Guide, visit the QRDA Project Tracking System.
For questions about the Quality Payment Program, contact or 866-288-8292

National Influenza Vaccination Week

National Influenza Vaccination Week is a national observance that highlights the importance of continuing influenza vaccination efforts through the holiday season and beyond. The Centers for Disease Control and Prevention (CDC) recommends annual influenza vaccination for everyone 6 months and older. It’s not too late to vaccinate – to help protect your patients, your staff, and yourself.

Medicare Part B covers:

Influenza virus vaccine once per influenza season
Additional influenza vaccines if medically necessary

For More Information:

Influenza Resources for Health Care Professionals (PDF) MLN Matters Article
Influenza Vaccine Payment Allowances (PDF) MLN Matters Article
CDC Influenza website
CDC Information for Health Professionals webpage
CDC Fight Flu Toolkit webpage
CDC Make a Strong Flu Vaccine Recommendation webpage

National Handwashing Awareness Week

Practicing hand hygiene is a simple and effective way to prevent infections. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics. Create a safe environment for your patients and staff.

Medicare Learning Network resources:

Infection Control: Hand Hygiene Video: Learn when to wash your hands and techniques to wash visibly and non-visibly dirty hands — run time 1:58
Infection Control: Hand Hygiene Web-Based Training Course: Learn about hand hygiene in patient care zones and nearby administrative areas; appropriate methods for maintaining good hand hygiene; and how to recognize opportunities for hand hygiene in a health care setting — with continuing education credit

Compliance

Cardiac Device Credits: Medicare Billing

A 2018 Office of the Inspector General (OIG) Report noted that payments reviewed for recalled cardiac medical devices did not comply with Medicare requirements for reporting manufacturer credits. Medicare incorrectly paid hospitals $7.7 million for cardiac device replacement claims, resulting in potential overpayments of $4.4 million. Manufacturers issued reportable credits to hospitals for recalled cardiac medical devices, but the hospitals did not adjust the claims with the proper condition codes, value codes, or modifiers to reduce payment as required.

CMS developed the Medicare Billing for Cardiac Device Credits (PDF) Fact Sheet to ensure that hospitals properly report manufacturer credits for cardiac devices and avoid overpayment recoveries. Additional resources:

Medicare Quarterly Provider Compliance Newsletter Volume 5, Issue 2 (PDF), January 2015
Medicare Claims Processing Manual, Chapter 3 (PDF), Section 100.8: Replaced Devices Offered Without Cost or With a Credit
Medicare Claims Processing Manual, Chapter 4 (PDF), Section 61.3.5: Reporting and Charging Requirements When a Device is Furnished Without Cost to the Hospital or When the Hospital Receives a Full or Partial Credit for the Replacement Device Beginning January 1, 2014
Hospitals Did Not Comply With Medicare Requirements For Reporting Certain Cardiac Device Credits OIG Report, March 2018

Claims, Pricers & Codes

Average Sales Price Files: January 2020

CMS posted the January 2020 Average Sales Price (ASP) and Not Otherwise Classified (NOC) pricing files and crosswalks on the 2020 ASP Drug Pricing Files webpage.

Home Health RAPs: Hold Starting January 1, 2020

Medicare Administrative Contractors (MACs) typically hold claims for a brief period each quarter when they implement system releases. This January, home health Requests for Anticipated Payment (RAPs) are affected by implementation of the Home Health Patient-Driven Groupings Model. MACs will hold RAPs with From Dates on or after January 1, 2020, and process them once the updates are complete.

Events

Hospital Price Transparency Special Open Door Forum — December 10

Tuesday, December 10 from 2 to 3 pm ET

This Special Open Door Forum allows stakeholders to ask questions about the recently released price transparency rules:

See the announcement (PDF) for more information.

Medicare Promoting Interoperability Program 2020 Webinar — January 16

Thursday, January 16 from 1 to 2 pm ET

During this webinar, CMS reviews major changes to the Medicare Promoting Interoperability Program for 2020, including:

2020 electronic health record reporting period
2015 edition CEHRT requirements
Objective/measure changes
Scoring

Attendees will also have the opportunity to ask questions during a Q&A session following the presentation.

MLN Matters® Articles

Overview of the Patient-Driven Groupings Model

A new MLN Matters Article SE19027 on is available. Learn about implementation of the new Patient-Driven Groupings Model for home health periods of care starting on and after January 1, 2020.

Payments and Payment Adjustments under the Patient-Driven Groupings Model

A new MLN Matters Article SE19028 on Payments and Payment Adjustments under the Patient-Driven Groupings Model (PDF) is available. Learn about changes for home health periods of care starting on and after January 1, 2020.

Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for Calendar Year (CY) 2020 - Recurring File Update

A new MLN Matters Article MM11500 on Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for Calendar Year (CY) 2020 - Recurring File Update (PDF) is available. Learn about updates to the base payment rate and the geographic adjustment factors.

Publications

Disproportionate Share Hospital — Revised

A revised Disproportionate Share Hospital Medicare Learning Network Fact Sheet is available. Learn about:

How to quality for an adjustment
Counting number of beds and patient days
Adjustment formulas

Federally Qualified Health Center — Revised

A revised Federally Qualified Health Center Medicare Learning Network Booklet is available. Learn about:

How to certify
Patient services and visits
Payment
Cost reports

Medicare Learning Network (MLN) Learning Management System (LMS) FAQs — Revised

A revised Medicare Learning Network (MLN) Learning Management System (LMS) FAQs Booklet is available. Learn how to:

Access the LMS
Find products
Take web-based training
Print your certificate

Multimedia

Clinical Labs Call: Audio Recording and Transcript

An audio recording (ZIP) and transcript (PDF) are available for the November 14 Medicare Learning Network call on the Clinical Diagnostic Laboratory Test Payment System: Data Reporting. Learn how to register in the system and submit then certify data.

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