This week in Medicare—3/13/2024
CMS Releases Eighth Annual Evaluation Report of the Independence at Home Demonstration
On February 23, CMS released its eighth annual Evaluation Report on the Independence at Home (IAH) demonstration. The IAH demonstration tests whether a payment incentive for providing home-based primary care reduces healthcare spending and improves the quality of care for high-cost, high-need fee-for-service Medicare beneficiaries.
The report analyzes how IAH impacted Medicare spending and patient care during 2021, the eighth year of the demonstration. CMS determined that the ambulatory care and support provided by the seven participating practices did not significantly reduce total spending or hospital utilization for Medicare beneficiaries.
CMS Releases Second Annual Evaluation Report for the Primary Care First Model
On February 26, CMS released its second annual Evaluation Report on the Primary Care First (PCF) model. Launched in 2021, the model aims to improve quality, improve patient experience of care, and reduce expenditures by increasing patient access to advanced primary care services. The PCF model offers capitated and visit-based payments, with the opportunity for performance-based adjustments, to total primary care payments if practices meet targets for acute hospitalizations or total cost of care and select quality metrics.
CMS determined that the PCF model has had minimal effects on hospitalizations and Medicare expenditures in 2022, but clarified that it did not anticipate finding improvements for these outcomes this early.
CMS Posts the 2024 National Impact Assessment Quality Measures Reports
On February 28, CMS published the fifth triennial National Impact Assessment of CMS Quality Measures Report that analyzes quality measure results from 2016 to 2021 across 26 quality and value-based incentive payment programs.
The 2024 report showed that improvements in measure performance—largely prior to the COVID-19 public health emergency (PHE)—were associated with positive impacts for millions of patients and substantial costs avoided. The findings showed that the COVID-19 PHE had major impacts on measure performance. More than 50% of the measures examined had rates that were worse than expected in 2021.
Revisions to Chapter 2 and Appendix F of the State Operations Manual (SOM) – Community Mental Health Centers (CMHC)
On March 2, CMS published a Memorandum to state survey agency directors regarding new regulations from the 2024 OPPS Final Rule regarding requirements for intensive outpatient (IOP) services, personnel qualifications for mental health counselors, and additional practitioners (marriage and family therapists) who may lead interdisciplinary team meetings as necessary. CMS is making changes to survey processes for CMHCs due to these new policies, and it revised guidance on CMHC certification and updated regulations and guidance in the ASPEN system to align with the regulatory updates.
Effective date: Immediately. Please communicate to all appropriate staff within 30 days.
CMS Updates National Plan and Provider Enumeration System (NPPES) to Include Additional Gender Options and P.O. Boxes Instead of Home Addresses
On March 4, CMS published a Notice in the Federal Register regarding changes to NPPES data elements. The NPPES will permit the selection of gender options beyond male and female to promote improved accuracy in publicly available data and support unique identification and enumeration of health care providers. The new options will be disseminated starting April 3, 2024.
For providers who do not have a physical location other than their home address, the NPPES will allow for a post office box or personal mailbox offered by a private delivery service to serve as a practice location address. These changes will be effective on April 3, 2024.
Data Snapshot: Biosimilar Cost and Use Trends in Medicare Part B
On March 6, the OIG published a Data Snapshot on biosimilar cost and use trends in Medicare Part B. The data snapshot provides supplemental information for the biosimilars and reference products previously analyzed in a September 2023 OIG report on biosimilar costs. The OIG analyzed quarterly ASP trends, differences in Part B payments, and HCPCS code use rates.
Final Decision Memo: Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndromes (MDS)
On March 6, CMS published a Final Decision Memo regarding the expansion of Medicare coverage for allogeneic HSCT under NCD 110.23. CMS finalized expanding coverage under the NCD to patients using bone marrow or peripheral blood stem cell products as well as umbilical cord blood stem cell products. CMS will cover this service when patients have myelodysplastic syndromes with risk scores of:
- ≥ 1.5 (Intermediate-2 or high) using the International Prognostic Scoring System (IPSS), or
- ≥ 4.5 (high or very high) using the International Prognostic Scoring System – Revised (IPSS-R), or
- ≥ 0.5 (high or very high) using the Molecular International Prognostic Scoring System (IPSS-M)
Coverage of all other indications for stem cell transplantation not otherwise specified will be made by the MACs.
Guiding an Improved Dementia Experience (GUIDE) Model Implementation
On March 7, CMS published Demonstrations Transmittal 12536, which rescinds and replaces Transmittal 12365, dated November 16, 2023, to revise the Background and Policy sections, revise BRs 13412.3, 13412.6.1, 13412.6.2.1, 13412.8.1, 13412.10, 13412.13-15, 13412.15.1-3, 13412.22, and 13412.28-30, add BRs 13412.3.1-2,13412.30.1, and 13412.32-40, delete BR 13412.25, update Appendices A-D, and add Appendix E.
The original transmittal was issued to implement the GUIDE Model, which is a demonstration that will test payment and service delivery models for people with dementia and their caregivers.
Effective date: April 1, 2024 - Analysis, Design and Coding; July 1, 2024 - Testing and Implementation
Implementation date: April 1, 2024 - Analysis, Design and Coding; July 1, 2024 - Completion of Coding, Testing, and Implementation
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 30.2, Effective July 1, 2024
On March 7, CMS published Medicare Claims Processing Transmittal 12529 regarding the regular quarterly updates to the NCCI PTP edits. The file should be available on or around May 17, 2024.
Effective date: July 1, 2024
Implementation date: July 1, 2024
Update to Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15, Section 110.8 Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) Benefit Category Determinations and Add Section 145 Lymphedema Compression Treatment Items
On March 7, CMS published Medicare Benefit Policy Transmittal 12532 to update Section 110.8 (DMEPOS Benefit Category Determinations) and add Section 145 (Lymphedema Compression Treatment Items) in Chapter 15 of the Medicare Benefit Policy Manual.
Effective date: October 1, 2023, for Medicare Benefit Policy Manual (MBPM), chapter 15,
section 110.8; January 1, 2024, for MBPM, chapter 15, section 145
Implementation date: May 6, 2024
Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 32, Section 90 for Coding Revisions to the National Coverage Determinations (NCDs)--July 2024 Change Request (CR) 13507
On March 7, CMS published Medicare Claims Processing Transmittal 12533 regarding updates to Chapter 32, Section 90 of the Medicare Claims Processing Manual. The changes reflect the recent quarterly updates to ICD-10 conversions and other NCD coding revisions.
Effective date: April 8, 2024
Implementation date: April 8, 2024
New Waived Tests
On March 7, CMS published Medicare Claims Processing Transmittal 12534 regarding new tests that were recently approved by the FDA as waived tests under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). The HCPCS codes for the 25 tests must have modifier QW to be recognized as a waived test.
CMS published MLN Matters 13546 on the same date to accompany the transmittal.
Effective date: April 1, 2024
Implementation date: April 1, 2024
CMS Releases Accomplishments for 2023
On March 8, CMS released a Report on its 2023 accomplishments. The report highlights CMS’ recent efforts that support its strategic pillars (Advance Equity, Expand Access, Engage Partners, Drive Innovation, Protect Programs, and Foster Excellence).