Recent Medicare Program Changes

Providers, suppliers and their billing staff need to be aware of the following recent changes to the Medicare program.

Medicare Outpatient Observation Notice (MOON)

Beginning March 8, 2017, hospitals and critical access hospitals (CAHs) must provide patients with a MOON notice. The MOON notice is a standardized notice to inform Medicare beneficiaries that they are outpatients receiving observation services and are not inpatients of a hospital or CAH. The MOON must be delivered to beneficiaries in Original Medicare (fee-for-service) and Medicare Advantage enrollees who receive observation services as outpatients for more than 24 hours. The hospital or CAH must provide the MOON no later than 36 hours after observation services as an outpatient begin. Hospitals and CAHs must provide both the standardized written MOON as well as oral notification.

The MOON is mandated by the Federal Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act), passed on August 6, 2015. Instructions for the MOON will be included as Section 400 of Chapter 30 of the Medicare Claims Processing Manual.

Region 1 and 5 RACs Audits Operational

Performant, the Centers for Medicare & Medicaid Services (CMS) Recovery Audit Contractor (RAC) has recieved the green light from the agency to begin auditing specific issues. States covered by Region 1 include MI, IN, KY, OH, VT, NH, ME, MA, RI, CT and NY. The RAC performs postpayment reviews to identify and correct Medicare claims that contain improper payments (overpayments or underpayments) that were made under Part A and Part B, for all provider types other than Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Home Health/Hospice. The Region 5 RAC audits postpayment reviews of DMEPOS and Home Health/Hospice claims nationally.

One audit issue of concern for physicians is the RACs identification of overpayments made when physicians/non-physician practitioners report visits with new-patient Evaluation and Management (E/M) codes for patients who do not meet the definition of a new patient. A related audit will seek to identify, based on CPT codes, those providers billing codes for New Patient visits (rather than established) when patients have been seen by the same provider in the last 3 years. Additional professional services, hospital and DME issues earmarked for audits are identified on Performant website.

NGS Informs Providers of Changes to Requirements for Expanded Problem Focused and Detailed E&M Codes

The National Government Services, a CMS Medicare contractor, has informed providers of changes for E&M coding for Expanded Problem Focused and Detailed CPT codes for services performed on and after 7/1/2017. Citing provider complaints regarding confusion over similar factors needed to demonstrate these levels of coding and subjectivity in post payment audits, NGS has issued the following revision to documentation requirements for these 2 codes:

Current Examination Requirement (prior to 7/1/2017)
Expanded Problem Focused: 2-7 body areas or organ systems
Detailed: 2-7 body areas or organ systems

Examination Requirement as of 7/1/2017
Expanded Problem Focused: 2-5 body areas or organ systems
Detailed: 6-7 body areas or organ systems

If you have questions regarding this article, Medicare or Medicaid enrollment, revalidation, revocation, denials, rejections, audits, or have other health care related questions please contact our office