This week in Medicare—1/17/2024
CMS Releases Second Annual Evaluation Report on End-Stage Renal Disease Treatment Choice Model
On January 4, CMS released the second annual Evaluation Report on the End-Stage Renal Disease (ESRD) Treatment Choice (ETC) Model. The ETC model establishes incentives for participating facilities and clinicians to encourage greater use of home dialysis and kidney transplantation, reduce Medicare expenditures, and preserve or enhance care quality. The report examines how the ETC Model impacted ESRD care and outcomes during calendar years 2021 and 2022.
The evaluation found no evidence that the ETC model impacted the use of home dialysis modalities, transplant waitlisting, and living donor transplantation. There was also no evidence that the model impacted Medicare spending, in-center dialysis patient experience of care, quality, mortality, or outcomes related to health equity or utilization.
CMS Highlights Efforts to Address Health Disparities in Rural Communities
On January 9, CMS published a Fact Sheet on its Rural Health Cross-Cutting Initiative aimed at sustaining and expanding critical health providers and services, expanding infrastructure, and driving innovation in rural healthcare. CMS highlighted its recent efforts in this initiative, such as participating in the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) model and designating a new Medicare provider-type, Rural Emergency Hospital.
CMS Recognized Presbyopia-Correcting (PC) IOLs and Astigmatism-Correcting (AC) IOLs
On January 10, CMS published a List of the IOLs (PC IOLs, AC IOLs, and both PC/AC IOLs) that it recognizes for payment. Each type is listed by manufacturer name in the document.
April 2024 Quarterly Update to HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement
On January 11, CMS published Medicare Claims Processing Transmittal 12449 regarding updates to the list of HCPCS codes subject to CB under the SNF PPS to incorporate the April 2024 coding updates.
Effective date: April 1, 2024
Implementation date: April 1, 2024
CMS Releases Final Evaluation Report for Next Generation Accountable Care Organization Model
On January 11, CMS published the sixth and final Evaluation Report on the Next Generation Accountable Care Organization (NGACO) Model. The NGACO Model, which ran from 2016 to 2021, tested whether high financial risk, more predictable payment flows, and flexibility in care delivery could reduce Medicare spending and improve value for Medicare beneficiaries. The report analyzes how participating entities responded to the model and performed throughout its six-year run.
The analysis revealed a $1.7 billion reduction in Medicare Parts A and B spending without an increase in ambulatory care-sensitive condition hospitalizations, unplanned 30-day hospital readmissions, and hospital readmissions from skilled nursing facilities. Overall, NGACOs earned more shared savings than shared losses relative to their benchmarks while participating in the model. Of note, the report showed that the model’s impact on spending, utilization, and care quality was most pronounced during the COVID-19 pandemic.
New Physician Specialty Code for Epileptologists
On January 11, CMS published Medicare Claims Processing Transmittal 12456 and Medicare Financial Management Transmittal 12456 regarding the establishment of a new physician specialty code for epileptologists (F6).
Effective date: July 1, 2024
Implementation date: July 1, 2024
Updates to Medicare Benefit Policy Manual and Medicare Claims Processing Manual for Marriage and Family Therapists (MFT) and Mental Health Counselors (MHC)
On January 11, CMS published Medicare Claims Processing Transmittal 12448 and Medicare Benefit Policy Transmittal 12448 regarding the incorporation of information into the manuals about MFTs and MHCs. This information includes the definition of these individuals and services, covered services, specialty codes, and more.
Effective date: January 1, 2024
Implementation date: February 12, 2024
Notice of New Interest Rate for Medicare Overpayments and Underpayments – 2nd Qtr FY 2024
On January 11, CMS published Medicare Financial Management Transmittal 12457 regarding the updated interest rate for Medicare overpayments and underpayments. The latest private consumer rate has been changed to 12.375%.
Effective date: January 18, 2024
Implementation date: January 18, 2024
Updating FISS Editing for Practice Locations to Bypass Non-OPPS Provider
On January 11, CMS published One-Time Notification Transmittal 12450 regarding an update to the FISS to bypass criteria for practice location service facility matching the information on the CMS 855A when the service facility location is a remote location of a hospital, on-campus remote location, or a non-OPPS provider.
Effective July 1, 2024
Implementation date: July 1, 2024
Implementation of System Edits for Direct Graduate Medical Education (DGME) and Kidney Acquisition Pass-Through Amount Fields of the Provider Specific File (PSF)
On January 11, CMS published Medicare Claims Processing Transmittal 12452 regarding the creation of FISS edits to ensure accurate data entry of the DGME and kidney acquisition pass-through amount fields of the PSF.
Effective date: April 3, 2023 – Effective for rate reviews occurring on or after April 3, 2023, for the purpose of computing the interim payment rates
Implementation date: July 1, 2024
System Updates to Lump Sum Utility for Addition of Wage Index Fields
On January 11, CMS published One-Time Notification Transmittal 12454 regarding an enhancement to the functionality of the FISS lump sum utility tool by adding new wage index fields to the utility.
Effective date: July 1, 2024
Implementation date: July 1, 2024
Overpayments to Method II CAHs Billing for Marriage and Family Therapist (MFT) and Mental Health Counselor (MHC) Services
On January 11, CMS published a Note in MLN Connects regarding payment edits for MFT and MHC services furnished in CAHs and billed under method II billing. CMS plans to complete the payment edits during the second quarter of 2024 and will pay CAH method II claims for MFT and MHC services at the Physician Fee Schedule rate for dates of service starting January 1, 2024. CMS said it will correct the overpayment by July 1, 2024, automatically and providers do not need to take any extra action.
Update to Section 20.2.1 and 20.2.5-20.2.7 on the Definitions of Dual-Eligible Special Needs Plans (D-SNPs) and Additional Requirements for Certain D-SNPs
On January 12, CMS published Medicare Managed Care Transmittal 130 regarding updates to the manual to better reflect current regulatory requirements for D-SNPs, such as updated information on frailty adjustments for D-SNPs, a new section describing Medicaid carve-outs, and more.
Effective date: January 12, 2024
Implementation date: January 12, 2024