Recent Medicare Updates for Healthcare Providers

Read the latest Medicare updates impacting prescriber enrollment requirement for Part D drugs, billing for telehealth services, and DME prior authorization in 2017.

Part D Prescriber Enrollment – Update

The Centers for Medicare & Medicaid Services (CMS) has delayed the full enforcement of the prescriber enrollment requirement for Part D drugs until January 1, 2019. Partial implementation of Medicare Part D integrity goals is on-going.

Rules enacted in the past couple of years require that “virtually all physicians and other eligible professionals, including dentists who write prescriptions for Part D drugs,” be enrolled in an approved status with Medicare or file a valid opt-out affidavit in order for their prescriptions to be covered under Part D. Prior to the recent extension, the deadline for enrollment/opt-out was January 1, 2017. CMS decided to delay the full implementation of the requirement and provide prescribers with an opportunity to enroll or opt-out to avoid adverse impact on beneficiaries.

The purpose of the Prescriber Part D rules are to ensure that Part D drugs are prescribed only by physicians and eligible professionals who are qualified to do so under state law and under the requirements of the Medicare program and who do not pose a risk to patient safety. By implementing these rules CMS hopes to improve the integrity of the Part D prescription drug program.

Prior to the full implementation of the Part D prescriber enrollment requirement CMS is taking other gradual measures to protect the Medicare program. For example, beginning in the second quarter of 2017, prescriptions written by sanctioned/excluded providers, including non-enrolled providers with a felony conviction in the last 10 years, will be denied at the point of sale. CMS also anticipates increasing provider enrollment by working with Part D plans and through direct notifications to all providers not enrolled in the program (via regular mail and email).

New Place of Service Code

Effective January 1, 2017, CMS is creating a new place of service (POS) code 02 for use by the physician or practitioner furnishing telehealth services from a distant site. The new POS code (POS 02: Telehealth) will have a descriptor “[t]he location where health services and health related services are provided or received, through telecommunication technology.” According to CMS, this new Telehealth POS code would not apply to originating site facilities billing a facility fee.

CMS also advises that under HIPAA, the effective date for nonmedical data code sets, of which the POS code set is one, is the code set in effect the date the transaction is initiated. It is not date of service.

Billing Medicare for telehealth services requires modifiers GT (via interactive audio and video telecommunications systems) or GQ (via an asynchronous telecommunications system). Medicare contractors will deny any telehealth services that are billed with POS code 02 but without the GT or GQ modifiers.

A First – DME Prior Authorization for 2 Items

For the first time two items of durable medical equipment (DME) will be subject to prior authorization requirements beginning on March 20, 2017 for New York, Illinois, Missouri, and West Virginia (nation-wide beginning in July 2017). DME subject to the prior authorization requirement include K0856 (power wheelchair, group 3 std., single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds) and K0861 (power wheelchair, group 3 std., multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds).

In announcing this new requirement in the federal register, CMS stated that prior to furnishing the item to the beneficiary and prior to submitting the claim for processing, a requester must submit a prior authorization request that includes evidence that the item complies with all applicable Medicare coverage, coding, and payment rules. Such evidence, for example, must include the order, relevant information from the beneficiary’s medical record, and relevant supplier-produced documentation. After receipt of all applicable required Medicare documentation, CMS/its review contractors will conduct a medical review and communicate a decision that provisionally affirms or non-affirms the request.

If you have questions regarding these new Medicare changes or have questions regarding Medicare or Medicaid payment or coverage requirements, enrollment, revalidation, revocation, sanctions, exclusion or other health law matter, please contact our office.