This Week in Medicare—11/6/2024
Medicare Shared Savings Program Continues to Deliver Meaningful Savings and High-Quality Health Care
On October 29, CMS published a Press Release to announce that the Medicare Shared Savings Program yielded over $2.1 billion in net savings in 2023, representing the most savings in the program’s history. Accountable care organizations (ACO) earned shared savings payments totaling $3.1 billion in 2023, which is also the most in the program’s history. Between the 2022 and 2023 performance years, ACOs also displayed statistically significant improvement in quality measures related to diabetes and blood pressure control, breast and colorectal cancer screening, and more.
Proposed Decision Memo: Implanted Pulmonary Artery Pressure Sensor for Heart Failure Management
On October 30, CMS published a Proposed Decision Memo on expanding Medicare coverage of pulmonary artery pressure sensor(s) (IPAPS) for heart failure management under Coverage with Evidence Development (CED). CMS is proposing IPAPS is covered for heart failure management when furnished according to an FDA market-authorized indication and specific patient, physician, and CED study criteria are met. All other uses of IPAPS are non-covered.
CMS initiated a 30-day public comment period at the time of publication. Comments are due by November 29.
Implementation of the Award for the Jurisdiction J (J-J) Part A and Part B Medicare Administrative Contractor (JJ A/B MAC)
On October 30, CMS published One-Time Notification Transmittal 12932, which rescinds and replaces Transmittal 12924, dated October 24, to change the date listed in the BR background section to December 8, 2024.
The original transmittal was issued to announce the new contract for the Jurisdiction J A/B MAC .
Effective date: September 1, 2024
Implementation date: December 8, 2024
Utilization of KX Modifier Medicare Physician Fee Schedule (MPFS) Payment for Dental Services Inextricably Linked to Covered Medical Services
On October 30, CMS published One-Time Notification Transmittal 12933, which rescinds and replaces Transmittal 12702, dated June 27, to change the implementation date for BRs 13649.4.2 and 12649.6.1 to July 1, 2025.
The original transmittal was issued to detail the usage of the KX modifier for dental services inextricably linked to covered medical services under the MPFS.
Effective date: July 1, 2025
Implementation date: July 1, 2025
Prohibition on Billing Qualified Medicare Beneficiaries
On October 31, CMS published an MLN Fact Sheet on rules for billing Qualified Medicare Beneficiaries (QMB). All Medicare providers and suppliers are prohibited from billing those in the QMB eligibility group for Part A or B cost-sharing, including deductibles, coinsurance, and copayments. The fact sheet includes information on QMB billing protection laws, the impact of improper billing, compliance tips, and resources for providers and suppliers.
Comprehensive Error Rate Testing (CERT) Medical Record Requests: Respond Timely
On October 31, CMS published a Message in MLN Connects from the CERT A/B MAC Education Task Force reminding providers to respond in a timely manner to CERT requests for medical records. MACs may adjust a provider’s CERT sampled claim and recoup the payment without a response.
CY 2025 Medicare Physician Fee Schedule (MPFS) Final Rule
On November 1, CMS published a draft copy of the CY 2025 MPFS Final Rule, which is scheduled to be published in the Federal Register on December 9. The rule reduces the conversion factor by 2.8% to $32.35 in CY 2025, down from $33.29 in CY 2024. Other policies in the rule include the following:
- Establishing coding and payment for caregiver training services for direct care services and supports
- Allowing payment of office/outpatient evaluation and management visit complexity add-on HCPCS code G2211 under certain conditions
- Extending certain telehealth flexibilities through 2025, including the waiver allowing federally qualified health centers and rural health clinics to bill for telehealth services
- Establishing coding and payment for a new set of advanced primary care management services under three new HCPCS G-codes (G0556, G0557, G0558)
- Approving several telecommunication technology flexibilities for opioid use disorder treatment services furnished by opioid treatment programs
The rule also includes policies related to supervision requirements, dental services, Part B drugs and biological products, and more.
CMS published a Press Release and Fact Sheet on the final rule, a Fact Sheet on Quality Payment Program changes, and a Fact Sheet on Medicare Shared Savings Program changes on the same date.
The rule is effective January 1, 2025.
CY 2025 Outpatient Prospective Payment System (OPPS) Final Rule
On November 1, CMS published a draft copy of the CY 2025 OPPS Final Rule, which is scheduled to be published in the Federal Register on November 27. CMS is finalizing a 2.9% increase to outpatient and ambulatory surgical center payment rates based on the projected 3.4% market basket update and 0.5% productivity adjustment. Other finalized policies in the rule include the following:
- Creating new Conditions of Participation for critical access hospitals that offer obstetrical services
- Establishing separate payment for non-opioid treatments (including drugs and devices) for pain relief
- Establishing a new add-on payment of $10 per dose of radiopharmaceuticals that use TC-99m derived from domestically produced Mo-99
- Adding 21 medical and dental surgical procedures to the ASC covered procedures list
- Narrowing the definition of “custody” to no longer include individuals who are on bail, on parole, on home detention, or required to reside in halfway houses
CMS published a Press Release and Fact Sheet on the final rule on the same date.
These changes are effective January 1, unless otherwise noted in the rule.
New Waived Tests
On November 1, CMS published Medicare Claims Processing Transmittal 12935 to inform contractors of a new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived test approved by the FDA. The HCPCS code for the newly approved test is 81515QW, and it must have modifier QW to be recognized as a waived test.
CMS published MLN Matters 13858 on the same date to accompany the transmittal.
Effective date: January 1, 2025
Implementation date: January 6, 2025