The Medicare Monthly Review, MMR-2011-01, January 2011 - CGS
The Medicare Monthly Review, MMR-2011-01, January 2011 - CGS The Medicare Monthly Review, MMR-2011-01, January 2011 - CGS
CR 7237 implements the following changes in ESRD payment for CY 2011:• A 2.5 percent increase to the ESRD composite rate portion of the blended payment amount, whichresults in a CY 2011 composite rate of $138.53 ($135.15 x 1.025)Note: This 2.5 percent increase does not apply to the drug add-on adjustment to the composite rate;• A wage index adjustment to reflect the current wage data;• A reduction in the wage index floor from 0.6500 to 0.6000, then after applying a budget neutrality of1.056929, the wage index floor is 0.64320;• A drug add-on adjustment of 14.7 percent;• Updated wage index values for the ESRD composite rate (to include the budget neutrality factor of1.056929); and• Updated wage index values for the ESRD PPS (which does not include the budget neutrality factor).In addition to the updates listed above, there have been several changes that affect how payment is madeto ESRD facilities beginning January 1, 2011. The Social Security Act (Section 1881(b)(14)(E)(i)) requires afour-year transition (phase-in) from the current composite payment system to the ESRD PPS, and Section1881(b)(14)(E)(ii) requires ESRD facilities to make a one-time election to be excluded from the transition:• Electing to be excluded from the four-year transition means that the ESRD facility would receivepayment for renal dialysis services based on 100 percent of the payment rate established under theESRD PPS, rather than a blended rate under each year of the transition based in part on the paymentrate under the current payment system and in part on the payment rate under the ESRD PPS.• Electing to go through the four-year transition means that (as of January 1, 2011) the ESRD facilitywould be paid in the first year a blended amount that will consist of 75 percent of the basic case-mixadjusted composite payment system and the remaining 25 percent would be based on the ESRD PPSpayment. For further details regarding the ESRD PPS transition, see the MLN Matters article related toCR 7064 (Transmittal R2033CP; dated August 20, 2010). That article is athttp://www.cms.gov/MLNMattersArticles/downloads/MM7064.pdf on the CMS Web site.For CY 2011, CMS will continue to update the basic case-mix composite payment system for purposes ofdetermining the composite rate portion of the blended payment amount during the ESRD PPS four-yeartransition (CYs 2011 through 2013).Additional InformationThe official instruction, CR 7237, issued to your FIs and A/B MACs regarding this change may be viewedat http://www.cms.gov/Transmittals/downloads/R135BP.pdf on the CMS Web site.If you have any questions, please contact your FIs or A/B MACs at their toll-free number, which may befound at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 76 MMR 2011-01, January 2011
Home Health Face-to-Face Encounter - A New Home HealthCertification RequirementMLN Matters® Number: SE1038Related Change Request (CR) #: N/ARelated CR Release Date: N/AEffective Date: January 1, 2011Related CR Transmittal #: N/AImplementation Date: N/AProvider Types AffectedThis article is for physicians certifying Medicare patients’ need/eligibility for home health benefits, homehealth agencies (HHAs), and beneficiaries.What You Need to KnowAs a condition for payment, the Affordable Care Act mandates that prior to certifying a patient’seligibility for the home health benefit, the certifying physician must document that he or she, or anallowed non-physician practitioner (NPP) has had a face-to-face encounter with the patient.Documentation regarding these encounters must be present on certifications for patients with starts ofcare on and after January 1, 2011. See the remainder of this article for details.BackgroundSince the inception of the benefit, the Social Security Act has required physicians to order and certify theneed for Medicare home health services. This new mandate assures that the physician’s order is based oncurrent knowledge of the patient’s condition.As a condition for payment, the Affordable Care Act mandates that prior to certifying a patient’seligibility for the home health benefit, the certifying physician must document that he or she, or anallowed NPP has had a face-to-face encounter with the patient.The Affordable Care Act describes NPPs who may perform this face-to-face patient encounter as a nursepractitioner or clinical nurse specialist (as those terms are defined in section 1861(aa)(5)of the SocialSecurity Act), who is working in collaboration with the physician in accordance with State law, or acertified nurse-midwife (as defined in section 1861(gg)of the Social Security Act, as authorized by Statelaw), or a physician assistant (as defined in section 1861(aa)(5)of the Social Security Act), under thesupervision of the physician.Home Health Prospective Payment System (HHPPS) Final Rule Implementation ProvisionsThe Centers for Medicare & Medicaid Services (CMS) implemented this provision of the Affordable CareAct via the HHPPS Calendar Year (CY) 2011 rulemaking. In that rule, CMS finalized the following:• Documentation regarding these face-to-face encounters must be present on certifications for patientswith starts of care on and after January 1, 2011.• As part of the certification form itself, or as an addendum to it, the physician must document whenthe physician or allowed NPP saw the patient, and document how the patient’s clinical condition asseen during that encounter supports the patient’s homebound status and need for skilled services.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 77 MMR 2011-01, January 2011
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CR 7237 implements the following changes in ESRD payment for CY <strong>2<strong>01</strong>1</strong>:• A 2.5 percent increase to the ESRD composite rate portion of the blended payment amount, whichresults in a CY <strong>2<strong>01</strong>1</strong> composite rate of $138.53 ($135.15 x 1.025)Note: This 2.5 percent increase does not apply to the drug add-on adjustment to the composite rate;• A wage index adjustment to reflect the current wage data;• A reduction in the wage index floor from 0.6500 to 0.6000, then after applying a budget neutrality of1.056929, the wage index floor is 0.64320;• A drug add-on adjustment of 14.7 percent;• Updated wage index values for the ESRD composite rate (to include the budget neutrality factor of1.056929); and• Updated wage index values for the ESRD PPS (which does not include the budget neutrality factor).In addition to the updates listed above, there have been several changes that affect how payment is madeto ESRD facilities beginning <strong>January</strong> 1, <strong>2<strong>01</strong>1</strong>. <strong>The</strong> Social Security Act (Section 1881(b)(14)(E)(i)) requires afour-year transition (phase-in) from the current composite payment system to the ESRD PPS, and Section1881(b)(14)(E)(ii) requires ESRD facilities to make a one-time election to be excluded from the transition:• Electing to be excluded from the four-year transition means that the ESRD facility would receivepayment for renal dialysis services based on 100 percent of the payment rate established under theESRD PPS, rather than a blended rate under each year of the transition based in part on the paymentrate under the current payment system and in part on the payment rate under the ESRD PPS.• Electing to go through the four-year transition means that (as of <strong>January</strong> 1, <strong>2<strong>01</strong>1</strong>) the ESRD facilitywould be paid in the first year a blended amount that will consist of 75 percent of the basic case-mixadjusted composite payment system and the remaining 25 percent would be based on the ESRD PPSpayment. For further details regarding the ESRD PPS transition, see the MLN Matters article related toCR 7064 (Transmittal R2033CP; dated August 20, 2<strong>01</strong>0). That article is athttp://www.cms.gov/MLNMattersArticles/downloads/MM7064.pdf on the CMS Web site.For CY <strong>2<strong>01</strong>1</strong>, CMS will continue to update the basic case-mix composite payment system for purposes ofdetermining the composite rate portion of the blended payment amount during the ESRD PPS four-yeartransition (CYs <strong>2<strong>01</strong>1</strong> through 2<strong>01</strong>3).Additional Information<strong>The</strong> official instruction, CR 7237, issued to your FIs and A/B MACs regarding this change may be viewedat http://www.cms.gov/Transmittals/downloads/R135BP.pdf on the CMS Web site.If you have any questions, please contact your FIs or A/B MACs at their toll-free number, which may befound at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. <strong>The</strong> information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.CPT codes and descriptors are only copyright 2<strong>01</strong>0 American Medical Association (or such other date publication of CPT)<strong>The</strong> <strong>Medicare</strong> <strong>Monthly</strong> <strong>Review</strong> 76 <strong>MMR</strong> <strong>2<strong>01</strong>1</strong>-<strong>01</strong>, <strong>January</strong> <strong>2<strong>01</strong>1</strong>
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