This week in Medicare—1/24/2024
Acute Hospital Care at Home Data Release
On January 16, CMS published a Fact Sheet to announce it is releasing data from the Acute Hospital Care At Home initiative regarding patient admissions, escalations of care, and unanticipated patient mortalities. The data covers a time period from November 27, 2020 – March 30, 2023. It is available by request from the Research and Data Assistance Center. CMS said it will release more data from the initiative in 2025.
Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with Revenue Code 0905 for Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC)
On January 16, CMS published One-Time Notification Transmittal 12460, which rescinds and replaces Transmittal 12392, dated December 5, 2023, to update the IOP rate in Section I.B Policy and in BR 13264.2.1 and to add provider education BR 13264.22. The original transmittal was issued to implement the IOP billing requirements for FQHCs and RHCs.
CMS published MLN Matters 13264 to accompany the transmittal.
Effective date: January 1, 2024
Implementation date: January 2, 2024
Updated OIG Work Plan
On January 16, the OIG updated its Work Plan with the following new items:
- Optometrists Billing for Part B Services for Medicare Enrollees in Nursing Facilities
- Audit of CMS Oversight of States' Use of Third-Party Contractors To Conduct Nursing Home Surveys
Final Rule: Advancing Interoperability and Improving Prior Authorization Processes
On January 17, CMS published a draft copy of a Final Rule regarding improving interoperability and reducing challenges related to prior authorization. The rule is geared toward Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid and CHIP managed care plans/entities, and Qualified Health Plan issuers on the federal exchanges, as it aims to improve electronic exchange of health care data through various APIs. It also includes requirements for payers to send prior authorization decisions within 72 hours for expedited requests and seven calendar days for non-urgent requests. It requires payers to provide a specific reason for denied prior authorization decisions and to publicly report certain prior authorization metrics. The rule also includes a new electronic prior authorization measure for certain hospitals and CAHs participating under the Medicare Promoting Interoperability Program and in MIPS.
CMS published a Press Release and Fact Sheet on the rule on the same date. Provisions are effective at various times as designated in the rule. The rule is scheduled to be published in the Federal Register on February 8.
Update to the Payment for Grandfathered Tribal Federally Qualified Health Centers (FQHC) for Calendar Year (CY) 2024
On January 18, CMS published Medicare Claims Processing Transmittal 12462 regarding updates to the grandfathered tribal FQHC PPS rate, which is $667 in CY 2024.
Effective date: January 1, 2024
Implementation date: January 2, 2024; April 1, 2024 – Date for MACs to complete adjustments
Guidance for the Implementation of the Office and Outpatient (O/O) Evaluation and Management (E/M) Visit Complexity Add-on Code G2211
On January 18, CMS published Medicare Claims Processing Transmittal 12461 to update guidance on the O/O E/M visit complexity add-on code G2211. This code should be used by medical professionals, regardless of specialty, with O/O E/M visits of any level.
Add-on code G2211 could be billed if the practitioner is the continuing focal point for all needed healthcare services (e.g., primary care physician) or furnishing ongoing care related to a patient’s single, serious, and complex condition.
CMS published MLN Matters 13473 on the same date to accompany the transmittal.
Effective date: January 1, 2024
Implementation date: February 19, 2024
Innovation in Behavioral Health (IBH) Model
On January 18, CMS published a Press Release to announce the start of the IBH Model, which aims to improve the quality of care and outcomes for adults with mental health conditions and/or substance use disorder by connecting them via community-based health centers with physical, behavioral, and social supports to manage their care. The model is available through both Medicare and Medicaid, and CMS will select up to eight states to participate in it. The model will launch in Fall 2024. CMS will release a Notice of Funding Opportunity in the spring.
CMS published an FAQ, Fact Sheet, and a Webpage about the model on the same date.
Organ Procurement Organization (OPO) Conditions for Coverage – Definition Clarification
On January 18, CMS published a Memorandum to CMS Location Offices to clarify the definition of “donor” in the OPO Conditions for Coverage. The clarification specifies that in terms of pancreata research and donation, the reference to “research” included in the definition of a donor specifically refers to research for islet cell transplantation. OPOs also may only count pancreata used for islet cell transplantation or research in reporting.
Effective date: Immediately. Please communicate to all appropriate staff within 30 days.