This week in Medicare—2/28/2024
CMS Updates Medicare Disparities Mapping Tool to Include Medicare Advantage Data
On February 13, CMS updated the Mapping Medicare Disparities (MMD) Tool to include 2018 Medicare Advantage data and new visual enhancements. The MMD tool is an interactive map that offers data on disparities between subgroups of Medicare beneficiaries in health outcomes, utilization, and spending.
CMS Issues Guidance on Updated Prospective Payment System for Certified Community Behavioral Health Clinic Demonstration
On February 15, CMS published Guidance on prospective payment system (PPS) methodologies for the Certified Community Behavioral Health Clinics (CCBHC) demonstration. The CCBHC demonstration is aimed at improving the availability, quality, and outcomes of ambulatory behavioral health services. The updated guidance addresses the high-cost and specialized care delivered through mobile and on-site crisis intervention services to individuals who are experiencing a substance use or mental health-related crisis. CMS introduced two additional PPS rate options for CCBHCs in the guidance, bringing the total number of options to four.
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That MediGold (Contract H3668) Submitted to CMS
On February 16, the OIG published a Report regarding Medigold’s compliance with federal requirements when submitting selected diagnosis codes for use in CMS’ risk adjustment program. The audit covers MediGold for contract number H3668 and focused on seven groups of high-risk diagnosis codes for payment years 2017 and 2018. The high-risk groups of diagnoses in the report include acute stroke, acute myocardial infarction, embolism, lung cancer, breast cancer, colon cancer, and prostate cancer.
For this report, the OIG selected a stratified random sample of enrollee-years, which represent individuals classified by condition and payment year. The OIG determined that most of the selected diagnosis codes that Medigold submitted to CMS did not comply with federal requirements. Of the 210 sampled enrollee-years, 189 had medical records that did not support the diagnosis code, resulting in $469,907 in net overpayments.
The OIG recommends that Medigold refund $2,183,514 in estimated net overpayments, identify and refund overpayments for similar instances of noncompliance that occurred outside of the audit period, and take the necessary steps to improve its existing compliance procedures for high-risk diagnosis codes.
Federally Qualified Health Center Booklet
On February 20, CMS updated the Federally Qualified Health Center MLN Booklet to add information on marriage and family therapists and mental health counselors, add the new FQHC services for 2024, update the rules for mental health in-person visits, and update information about vaccines.
Rural Health Clinics Booklet
On February 20, CMS updated the Rural Health Clinics MLN Booklet to add information on marriage and family therapists and mental health counselors, add information about general care management services, provide information on intensive outpatient program services, add links to rural health reports and publications, and more.
Proper Use of Modifiers 59, XE, XP, XS, & XU
On February 20, CMS updated an MLN Fact Sheet on modifier -59 and the EPSU modifiers to add information on the use of modifier 59 in rural health clinics and federally qualified health centers.
Telehealth Services
On February 20, CMS updated the Telehealth Services MLN Fact Sheet to add the new CPT and HCPCS codes for CY 2024, provide information on new and expanded telehealth services, revise information about place of service codes, and more.
Medicare Coverage of Diabetes Supplies
On February 20, CMS published an MLN Fact Sheet on Medicare coverage of diabetes supplies. The fact sheet walks through what’s covered, what isn’t covered, and claims/payment information for blood glucose testing supplies, durable insulin pumps, and therapeutic shoes and inserts. It also goes through information about coverage under Part D.
Change Request (CR) to Implement the Medicare Program Final Action: Treatment of Medicare Part C Days in the Calculation of a Hospital’s Medicare Disproportionate Patient Percentage
On February 21, CMS published One-Time Notification Transmittal 12513 regarding the treatment of Medicare Part C days in the calculation of a provider’s Medicare Disproportionate Share Hospital adjustment. CMS previously established policies for this process in a final rule published on June 9, 2023, but had to delay implementation due to litigation.
The transmittal instructs MACs to move forward with implementing the requirements in the final rule.
Effective date: March 25, 2024
Implementation date: March 25, 2024 - NOTE: MACs shall begin work once this CR is placed on their contract.
Updates of Chapter 4, Chapter 8, and Exhibits in Publication (Pub.) 100-08, Including Prioritization and Payment Suspension Language Guidance
On February 22, CMS published Medicare Program Integrity Transmittal 12515 regarding updates to Chapter 4, Chapter 8, and Exhibits in the Medicare Program Integrity Manual. The chapter updates instruct Unified Program Integrity Contractors (UPIC) on payment suspension language and how to prioritize Accountable Care Organization referrals. The guidance in the Exhibits section is being revised to provide necessary updates to the model payment suspension letters.
Effective date: March 25, 2024
Implementation date: March 25, 2024
Manual Updates for Clarification on Services Under the Medicare Hospice Benefit for Dually Eligible Veterans
On February 22, CMS published Medicare Benefit Policy Transmittal 12516 regarding updates to Chapter 9 of the Medicare Benefit Policy Manual. Upon electing the Medicare hospice benefit, beneficiaries waive the right to Medicare payment for any services related to the terminal illness and related conditions during a hospital election. CMS clarified that this election does not preclude Veterans’ eligible beneficiaries from receiving services not included in the hospice plan of care, and which are furnished and paid under the beneficiaries’ VA benefits, in addition to Medicare hospice services.
Effective date: March 25, 2024
Implementation date: March 25, 2024
Update of Internet Only Manual (IOM), Pub. 100-04, Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims
On February 22, CMS published Medicare Claims Processing Transmittal 12517 to update the title of Section 50 and add condition codes 74 and 80 to Section 50.3 of Chapter 8 of the Medicare Claims Processing Manual.
Effective date: March 25, 2024
Implementation date: March 25, 2024
Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
On February 22, CMS published Medicare Claims Processing Transmittal 12519 regarding the quarterly update to the CLFS.
CMS published MLN Matters 13541 on the same date to accompany the transmittal.
Effective date: April 1, 2024
Implementation date: April 1, 2024
Fourth Policy Change Request (CR) Regarding Implementation of the Provider Enrollment, Chain and Ownership System (PECOS) 2.0
On February 22, CMS published Medicare Program Integrity Transmittal 12514 regarding updates to Chapter 10 of the Medicare Program Integrity Manual concerning the implementation of PECOS 2.0. This CR provides updates to applicable instructions in sections 10.3, 10.5, and 10.6.
Effective date: March 25, 2024
Implementation: March 25, 2024
Report of Hospice Election for Part D (Response File)
On February 22, CMS published One-Time Notification Transmittal 12518, which rescinds and replaces Transmittal 12331, dated October 26, 2023, to add BRs 13348.5 and 13348.6. CMS instructed MACs to send the data specified in the attachment to the Virtual Data Center by February 23, 2024. CMS plans to create the UAT test file and send it to the MACs on or around March 4, 2024.
The original transmittal was issued to define the response file related to CR 13202 for the hospice Part D file project to identify records that did not pass RelayHealth intake edits.
Effective date: April 1, 2024
Implementation date: April 1, 2024
OIG Single Audits Webpage
On February 22, the OIG published a new Webpage on Single Audits. This educational resource is now available and will help strengthen users’ understanding of the scope, and improve the quality, of Single Audits. The webpage highlights OIG oversight activities, compliance tools and resources, and frequently asked questions.
Livanta Short-Stay Review – Electrolyte Abnormalities
On February 22, Livanta published the January edition of its Claims Review Advisor. This edition covers short-stay reviews for electrolyte abnormality diagnoses associated with MS-DRGs 637-641. Livanta found that short-stay review error rates for DRGs 640 and 641 from October 2021 through December 2023 were both above 10%.
CY 2025 OPPS Preliminary Rate-Setting Data Two Times File
On February 23, CMS published a Download Link for the CY 2025 OPPS Preliminary Rate-Setting Data Two Times File, which contains data from January – September 2023.