Latest News | IP CAH

Federal Register – CMS-3244-F; FR 5/16/12 – Final rules

The Centers for Medicare and Medicaid Services (CMS) May 10 issued a final rule, “Reform of Hospital and Critical Access Hospital Conditions of Participation” (CoPs). The revisions to the CoPs are part of the government’s response to Executive Order 13563, “Improving Regulations and Regulatory Review.” The changes include:

• One governing body will be allowed to oversee multiple hospitals in a multi-hospital system, and a member or members of the hospital’s medical staff must be included on the governing body;
• Hospitals will have the flexibility to include other practitioners as eligible candidates for the medical staff with hospital privileges to practice in the hospital in accordance with state law;
• Elimination of the requirement for authentication of verbal orders within 48 hours; authentication timeframes will be established according to state law; and
• All orders, including verbal orders, must be dated, timed, and authenticated by either the ordering practitioner or another practitioner who is responsible for the care of the patient.

CMS Issues Final Rules on Hospital Conditions of Participation

Critical Access Hospital Fact Sheet

From MLN Matters – Updated January 2012

The MLN Matters fact sheet for Critical Access Hospitals was updated in January 2012.  These fact sheets provide very useful overview information concerning the numerous Medicare program payment systems.

Important Billing Information for CAHs Paid under the Optional Method Regarding Primary Care Incentive Payment Program (PCIP) 

CMS E-mail Notice 11/17/11:

CAH providers were instructed to submit their National Provider Identifiers (NPIs) using the ‘other provider’ field located in loop 2310C on the 4010A1 electronic claim format effective Friday, April 1, 2012. 

With the implementation activities to convert from the Accredited Standards Committee (ASC X12) version 4010A1 to the version 5010A2 format, loop 2310C was redefined to mean ‘other operating physician’.  For providers using the 837I 5010A2 format, the correct loop is 2310D, ‘rendering physician’, however, Medicare systems are not updated to assign PCIP bonus payments to the NPI reported in this field.  As a result, CMS plans to update system and billing instructions to address this change. 

In the meantime, to ensure there is not a delay in the PCIP bonus payments, providers shall continue to submit claims using the ‘other provider’ field, loop 2310C rather than in loop 2310D until further notice from CMS.

Payment for Multiple Surgeries in a Method II CAH

Transmittal R2333CP – 10/28/11

Summary of Changes:

This instruction implements the multiple procedure payment reduction policy for CAH method II providers.

Prosser Memorial Hospital – FYE 12/31/04

PRRB  2011– D38

The CAH Provider filed an appeal regarding their Medicare Ambulance reimbursement.  They contended that the hospital should be reimbursed on a cost basis for their ambulance service.

Statement of the Case

Prosser Memorial Hospital (Provider) is a Critical Access Hospital (CAH) located in Prosser, Washington. For the cost reporting period ended December 31, 2004, the Provider claimed the actual cost of its ambulance services. Noridian Administrative Services (Intermediary) audited the cost report and determined the Provider did not qualify for cost based reimbursement for the ambulance services because other ambulance services existed within a 35 mile radius of the hospital. The Intermediary adjusted the ambulance service costs by applying the ambulance fee schedule.

The Provider contended that while there were other ambulance services within the 35 mile radius they were in place only to respond to 911 emergency calls.  They further stated that as a “Necessary Provider CAH” that the 35 mile ambulance service rule did not apply.

The PRRB ruled that the Provider was reimbursed properly and denied the Provider’s request.  The Board stated that the provision in “…42 CFR Section 413.70(b)(5) are clear in establishing that ambulance services furnished by CAHs, or entities owned and operated by them, are paid for the services based on reasonable cost, thereby exempting them from the ambulance fee schedule, but only if there is not other ambulance provider or supplier within a 35-mile drive of the CAH.”

CMS Transmittal 2232

Transmittal Summary of Changes:

Prior to the regulation change made in the fiscal year (FY) 2011 Inpatient Prospective Payment System (IPPS) final rule, if a CAH chose to be paid under the optional method it was required to make its election on an annual basis. However, in the FY 2011 IPPS final rule, we changed the regulations for the optional method election such that effective for cost reporting periods beginning on or after October 1, 2010 if a CAH elected the optional method in its most recent cost reporting period beginning before October 1, 2010 or chooses to elect the optional method on or after October 1, 2010, that election remains in place until the CAH submits a termination request to its FI or A/B MAC.