This week in Medicare—11/8/2023

November 8, 2023
Medicare Insider

CY 2024 Home Health Prospective Payment System (HH PPS) Final Rule

On November 1, CMS published a draft copy of the CY 2024 HH PPS Final Rule, which is scheduled to be published in the Federal Register on November 13. The rule finalized a -2.890% permanent adjustment to the home health 30-day payment rate and 30-day unit of payment to account for changes in aggregate expenditures as a result of the implementation of the Patient Driven Groupings Model (PDGM). This adjustment is half the full permanent adjustment of -5.779%, and therefore significantly changes payment amounts from the proposed rule. CMS estimates that the aggregate home health payment rate update will be a 0.8% increase in 2024 rather than the 2.2% decrease projected in the proposed rule.  

CMS also finalized a change to rebase and revise the home health market basket for the first time since CY 2019 by adopting a 2021-based home health market basket, recalibrate PDGM case-mix weights and the LUPA thresholds using CY 2022 data, codify the statutory requirements for negative pressure wound therapy (NPWT) which provide separate payment for the device only, and more.

CMS published a Fact Sheet on the rule on the same date. Regulations in the rule are effective January 1, 2024.


Proposed Rule: Establishment of Disincentives for Health Care Providers That Have Committed Information Blocking

On November 1, CMS published a Proposed Rule in the Federal Register regarding the implementation of a provision from the 21st Century Cures Act aimed at stopping information blocking. This rule would establish three disincentives for healthcare providers who have been found by the OIG to have engaged in information blocking. These include:

  • Removing the hospital’s ability under the Medicare Promoting Interoperability Program to be a meaningful EHR user in an applicable EHR reporting period, resulting in payment losses
  • Removing a clinician or group’s ability under the Promoting Interoperability performance category of the Merit-based Incentive Payment System (MIPS) to be considered a meaningful user of certified HER technology in a performance period, resulting in a 0 score in that category
  • Preventing a health care provider that is part of an accountable care organization (ACO) or ACO participant from participating in the Medicare Shared Savings Program

Comments on the rule are due by January 2, 2024.


Revisions and Deletions to Medicare Financial Management Manual, Chapter 4, Debt Collection Related to Extended Repayment Schedules (ERS) and Debt Management

On November 1, CMS published Medicare Financial Management Transmittal 12346, which rescinds and replaces Transmittal 12323, dated October 20, to remove the recoupment of good faith payment instructions from sections 50.1 and 50.2. The original transmittal was published regarding revisions and deletions to the manual due to changes to the ERS process that enhance debt management and procedure efficiency.

Effective date: October 30, 2023

Implementation date: October 30, 2023


CY 2024 Outpatient Prospective Payment System (OPPS) Final Rule

On November 2, CMS published a draft copy of the CY 2024 OPPS Final Rule, which is scheduled to be published in the Federal Register on November 22. Although CMS initially proposed a 2.8% increase to outpatient and ambulatory surgical center (ASC) payment rates in the CY 2024 OPPS proposed rule, it finalized a 3.1% increase to both. This update is based on a projected hospital market basket percentage increase of 3.3%, reduced by a 0.2% productivity adjustment.

CMS also established the Intensive Outpatient Program (IOP) benefit in the final rule. The IOP benefit will create a distinct outpatient program of psychiatric services for individuals with acute mental illness or substance use disorder. The rule includes the scope of benefits, physician certification requirements, coding and billing, and payment rates under the IOP benefit.

Other finalized proposals include the following:

  • Refinement of existing coding for remote mental health services to allow for multiple units to be billed daily, creating a new untimed code to describe group psychotherapy, and delaying in-person visit requirements until the end of CY 2024
  • Assignment of over 240 dental codes to clinical APCs
  • Addition of 26 separately payable dental surgical procedures to the ASC covered procedures list and 78 ancillary dental services to the list of covered ancillary services
  • Modifications to hospital price transparency requirements and enforcement provisions that standardize the machine-readable file format and require hospitals to encode their standard charge information in a specific way, place a footer on the hospital homepage that links to the machine-readable file, and ensure that a .txt file is included that features the machine-readable file to make those more accessible to the public, and more
  • Reimbursement for 340B drugs at average sales price (ASP) plus 6%

CMS published a Fact Sheet and Press Release on this final rule, as well as a Fact Sheet on updated hospital price transparency policies.

These regulations are effective January 1, 2024, unless otherwise noted in the rule.


Update to Medicare Programs of All-Inclusive Care for the Elderly (PACE) Manual, Chapter 4 – Enrollment and Disenrollment

On November 2, CMS published Programs of All-Inclusive Care for the Elderly (PACE) Transmittal 12338 regarding an update to the Internet-Only Manual to replace the existing chapter guidance in the manual with a hyperlink to the updated PACE Chapter 4 enrollment and disenrollment guidance on the CMS website.

Effective date: December 5, 2023

Implementation date: December 5, 2023


CY 2024 Medicare Physician Fee Schedule (MPFS) Final Rule

On November 2, CMS published a draft copy of the CY 2024 MPFS Final Rule, which is scheduled to be published in the Federal Register on November 16. The rule reduces the conversion factor from $33.89 in 2023 down to $32.74 in 2024, a 3.4% decrease. Some of the other policies finalized in the rule include:

  • Aligning its definition of the “substantive portion” of a split/shared E/M visit with the AMA CPT Editorial Panel’s definition through at least the end of CY 2024. That definition reads as “the definition of ‘substantive portion’ means more than half of the total time spent by the physician and NPP performing the split (or shared) visit, or a substantive part of the medical decision making as defined by CPT.” The definition of substantive portion for critical care services will be more than half the total time spent by the physician and NPP performing the split (or shared) visit.
  • Reintroducing E/M add-on code G2211 for office visits to recognize the additional resource costs for complex patients, although CMS is revising some of the initial policies it had planned to include when this code was first proposed in the CY 2021 MPFS rule.
  • Implementing several telehealth policies from the Consolidated Appropriations Act of 2023, such as expanding the definition of telehealth practitioners, temporarily expanding the scope of telehealth originating sites, delaying requirements for in-person visits prior to initiating mental health telehealth services, and more.
  • Paying for telehealth services furnished to people in their homes at the non-facility rate beginning in CY 2024.
  • Increasing the threshold for the KX modifier to $2,330 (up $10 from the 2023 threshold of $2,320) and conducting targeted medical reviews for any subsequent expenses once a patient’s expenses reach $3,000.

The rule also addresses topics such as diabetes screening tests, supervision requirements for remote therapeutic monitoring, dental payment policies, and more.

CMS published a Press Release and Fact Sheet on the final rule, a Fact Sheet on Quality Payment Program to all appropriate staff within 30 days.